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HomeMy WebLinkAbout01-3280 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff : : vs. : CIVIL ACTION - LAW : RUTH Iq. GILBERT, : GAlL E. HAYWOOD and : JOHN E. GILBERT : Jointly and Severally, : Defendants : 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 is served, by entering a written appearance, personally of by attomey, and I~ling in waiting with the Court your defenses or oblections 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 document, or for any other claim or relief requested by he Plaintiff. You may lose money or property or other right important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU OO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH TO FIND OUT WHERE YOU CAN GET LEGAL HELP. NOTICIA Le han demandado a used en la cone. Si used quaere defensas de esas demandas expuestas en las paglnas, slgulentes, used tiene viente (20) dias de plazo al partir de la fecha de lademanda y la notiflation. Used debe presentar una apadencla escrita o en persona o por abogado y archlvar en la cone en forma escdta sos defensas o sus obleclones a last demandas en contra de su persona. Sea avisado clue si used no se deflenda, la cone tomara medidas y psedldo entrar una orden contra used sin prevlo avlso o noti§caclon y por cualquler quela o allvlo que es pedido en la petition de demanda. Used puede perder dinero o sus propledades o otros derechos importantes para used. LLEVE ESTA DElqANDA A UN ABODOAGO IlqMEDIATAlqENTE. SI NO TIENE ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO VAYA EN PERSONA O LLAlqE POR TELEFONO A LA OFICINA CUYA DIRECCION SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR ASSITANCIA LEGAL. Lawyer Referral Ser~tce Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, : NO. ~/- $ '~ '~ ~.~..,.tZ ~'7'~.~.*-,~ Plaintiff : : vs. : CIVIL ACTION - LAW : RUTH M. GILBERT, : GAlL E. HAYWOOD and : JOHN E. GILBERT : ]olnrJy and Severally, : Defendants : COMPLAINT AND NOW, this ~1 day of /~ , 2001, comes the Plaintilf, HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson 6: Associates, P.C., and files the within Complaint and in support avers as follows: I. Plaintiff, HCR Manor Care (hereinafter referred to as "Plaintiff"), is a health care provider qualified to conduct business In the Commonwealth of Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 173 i 5. 2. Defendant, Ruth I~. Gilbert, hereinafter referred to as "Defendant Ruth"), is an adult individual with a last known address of 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania ! 7013 2. Defendant, Gail E. Haywood, (hereinafter referred to as "Defendant Gail"), is an adult Individual with a last known address of 9 ! 6 Cora Street, Joliet, Illinois 60435. 2 3. That Defendant Gall represented to be Legal Representative and/or Responsible Party for Ruth M. Gilbert. Defendant Gall is the daughter of Ruth Gilbert. 4. Defendant, John E. Gilbert, (hereinafter referred to as "Defendant John"), is an adult individual with a last known address of 517 Hig~ Street, Elizabethtown, Lancaster County, Pennsylvania ! 7022. 5. That the invoices for Defendant Ruth were forwarded to the home of Defendant John for payment of same. 6. That on or about January 29, 2000, through the present, Ruth M. Gilbert was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein and collectively marked as Exhibit "A". 7. That on or about January 29, 2000, Defendant Gall, as Ruth Gilbert's Power of Attorney, executed an Admission Agreement which Agreement outlined various terms of residential health care services to be provided by Plaintiff and the Responsible party therefor. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and collectively marked as Exhibit "B". 8. That Plaintiff submitted to Defendants a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. Said Statement of Account has been previously Identified as Exhibit "A" and incorporated herein by reference. 9. That Defendant s did not object to the above mentioned Statement of Account submitted by Plaintiff to Defendants. ! O. As of May 2, 20OI, the balance due, owing and unpaid on Ruth M. Gilbert's account as a result of said charges is the sum of Fifty-Four Thousand Two Hundred Thirty-Six and 42/1 O0 Dollars ($54,236.42). See Exhibit "AT previously identified and incorporated herein. I I. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Ruth's account balance, all to the damage and detriment of the Plaintiff. ! 2. Plaintiff has made numerous requests to Defendant Gail, as Legal Representative and/or Responsible Party, for Ruth H. Gilbert, demanding that the sums due and owing to Plaintiff be paid, and Defendant Gail, as Legal Representative and/or Responsible Party for Ruth lq. Gilbert, has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Ruth.. 13. Plaintiff has made numerous requests to Defendant John, as a Responsible Party and as the person to whom all of Defendant Ruth's bills were sent, demanding that the sums due and owing to Plaintiff be paid, and Defendant John, as a Responsible Party of Defendant Ruth, has ignored his obligation to pay necessary and appropriate bills and obligations for his mother, Defendant Ruth. 14. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. See Exhibit "B" previously identified and incorporated herein. 15. As of the date of the within Complaint, the amount of Interest that has accrued on the past due balance is the sum of Twelve Thousand Two Hundred Fifty- One and 50 / 100 Dollars ($12,251.50). 16. Plaintiff has retained the services of the law firm of Wolfson ~ Associates, P.C., In the collection of the amounts due from Defendants. 17. Pursuant to Section 1, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitied to receive and Defendants have agreed to pay reasonable attorney's fees and all court costs If the account is referred to an attorney for collection. See Exhibit "B" previously Identified and Incorporated herein. 18. As of the filing of this Complaint, Plaintiff has Incurred reasonable attorney's fees from the law office of Wolfson ~ Associates, P.C., in the collection of the amounts due and owing by Defendants, Incident to the within action, and Plaintiff shall continue to Incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. 19. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing Is the sum of Sixteen Thousand Two Hundred Seventy-One and 29/100 Dollars ($16,271.29 ). 20. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 5 21. The amount In controversy exceeds the Jurisdictional amount requiring compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Gall E. Haywood and ~]ohn E. Gilbert for Ruth M. Gilbert, jointly and severally, in the amount of Fifty-Four Thousand Two Hundred Thirty-Six and 42/1 O0 Dollars ( $ 54,236.42), contractual Interest In the amount of Twelve Thousand Two Hundred Fifty-One and 50/I 00 Dollars ($12,251.50), reasonable attorney's fees in the amount of Sixteen Thousand Two Hundred Seventy-One and 29/I 00 Dollars ($16,271.29), the costs of this action and such other relief as the Court deems proper and lust. Respectfully Submitted, WOLFSON ~ ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 I.D. No. 20617 Attorney for Plaintiff 6 EXHIBIT "A" MANORCARE CARLISLE 372 946 NALNUT BOTTOM ROAD CARLISLE, PA 17013 PAGE 3 (717)-249-0085 JOHN GILBERT PRZVATE FOR RUTH GILBERT ROOM 100 -A 517 HIGH STREET ELIZABETHTOWN, PA 17022 PJeaseRelumThisPo~on W~th Your Paymen{ GILBERT, RUTH ~ 20015 05/0?/00 02/28/01 ~VICE CODE SERVICE RENDERED CHARGES CREDITS FWD FROM PRECEDING STMT 32,964.48 /31/00 AD3 REC R & 6/$0 4,123.00 !30/00 AOJ REC NON LE6ENO ./3~/00 AD3 REC R & B 30 3,990 /31/00 ADJ REC LEGEND 550 24 '31/0~ AD3 REC NON LEGEND 139 74 !31/00 ADJ REC R & B 31 4,123 ;30/00 ADJ REC LEGEND 159 68 '30/00 ADJ REC NON LE6ENO 9 '30/00 ADO AEC WOUND TREATMENT 48.00 "30/00 AOJ REC R & B 3e 3,990.00 '31/00 ADJ REC R & B 31 4,123.00 '31/01 AO3 CABLE RENTAL 5.90 PAYMENT DUE BY THE 10TH OF THE NONTH 54,236.42 AMOUNT DUE NANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE. PA 17013 (717)-249-0085 PRIVATE 30HN GILBERT fOR RUTH GILBERT ROOM lO0 -A 5[7 HIGH STREET Please Return This Potion ELIZABETHTOWN, PA 17022 With Your Payment GILBERT. RUTH M 20913 05/07/00 02/28/01 /01/01 BALANCE FORWARD 8,004 50 /01/01 111GG BEAUTY SH./OP WASH 1/18 QTY i 9 00 /01/01 11100 BEAUTY SHOP WASH 1/25 QTY i 9 BO /01/01 11100 BEAUTY AND BARBER QTY I 9 O0 /01/01 11100 BEAUTY W & S 1/4 CITY I 9 eO /01/01 11100 BEAUTY [4 & S 1/11 CITY i 9 00 /28/01 11600 CABLE RENTAL CITY I 5 OG /13/01 29001 PHARMACY LEGEND QTY i 293 17 /05/91 30001 PHARMACY NON LEGES'iD CITY I 10 00 /2B/01 51501 WOUND TREATI~ENT CITY 56 448 O0 /07/01 11100 BEAUTY AND BARBER QTY I 9 00 /15/01 11100 BEAUTY AI'4D BARBER QTY 1 9 O0 /01-02/28/01 ROOM CHARGE 4,123 09 /01-03/31/01 ADV ROOM CHARGE 4,123.00 SUB TOTALS 17,069.67 .00 CARRIED FWD AMOUNT DUE MANORCARE CARLISLE 372 940 WALNUT BOTTON ROAD CARLZSLE, PA 17013 (717)-249-0085 PAGE 2 $OHN GZLBERT PRIVATE FOR RUTH GZLBERT 517 HZGH STREET ROOM 100 -A ELIZABETHTONN, PA 17022 PleaseRerurnThisPon~on With Your Paymenl GILBERT, RUTH H .................... 20013 05/07/00 02/28/01 ATE OF FWD FROM PRECEDING STMT /31/00 ADJ REC LEGEND 17,069.67 .00 · /31/00 ADa REC NON LEGEND 124.94 /31/00 AD3 REC WOUND TREATMENT 7.95 /31/00 AD~ REC R & G 6 464.00 /31/00 AD3 REC R & 8 25 798.00 ./31/00 AO3 REC NON LEGENO 3,325.00 /31/00 AD3 REC R & B 25 DAYS 3.39 /30/00 ADJ REC NON LEGEND 3,300.00 /30/00 AD~ REC R & B 22 2.65 '/30/00 AD~ REC R & B 8 2,904.00 /31/00 AD3 REC NON LEGEND 1,016.00 /31/00 ADJ REC R & 8 31 .90 /31/00 AD3 REC NON LEGEND 3,937.00 10.98 SUB TOTALS 32.964.48 .00 CARRIED FND AMOUNT DUE EXHIBIT "B" HCR Manor Care ADMISSION AGREEMENT This Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities ofthe panics with respect to the Resident's stay at this HCR Manor Cafe's Health Care Center ("Center"). ,,dmiss,o. D.,e / - D - Deposit: $ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGHTS AND RESPONSH~ILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (10b) day of each month. '~he Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care Organization (see Section 1.06). 1.02 ~. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such 'Ancillary Charges' are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth (10b) day of the month. 1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 Indenendent Providers. The Resident shall be directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: ~/~edicare, ,~edicaid and/or VA. Medicare may pay for some or all of the Resident's care. If ~'ledicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take su~ legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Pavors and Managed Care Or,,anizations. Ifa Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HlVlO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If'the Center has not executed a provider agreement with the Resident's third party payor, the Center will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for l%.(edicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five ('$) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 A~)nlication for Benefits. It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This Agreement serves as a written notice that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. 1.11 ~¢ian. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of' the Center. At the time of' admission, the Resident must supply the Center with the name of his/her personal physician. Ifthe Resident changes physicians at any time aRer admission, the Resident and/or Legal Representative must immediately notify the Center of' the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of' choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSIBILITY OF TI:I'E LEGAL REPRESENTATIVE 2.01 Legal Authority. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 A~reement to Make Payments on Behalf Of' Resident The Legal Representative agrees to pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and charges provided for in this Agreement. 2.03 Reauested Items. The Legal~ Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of.Resident's Funds. Ir'the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is made. If' the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 4 2.05 Cooneration for Financial Assistance. If'the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center· It' aRer notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Resoonsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. IH. RIGHTS AND RESPONSrRILITlr~s OF THE CENTER 3.01 Room and Standard Services. As pan of the Room and Board Rate, the Center shall fi~rnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days at, er disch/trge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days ofthe Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third party payor or managed care organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activitiesi and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses ofthe photograph for Center and staffto identify the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security AdminiStration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. £ At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds 6 Authorization and any other related documents. See Attachment H-I and g. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). h. Social Service Agencies and Advocacy Groups addresses and phone numbers. Sec Attachment I (Center Supplement). i. Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). j. The location in the Center where the names, addresses and telephone numbers of' state client advocacy groups, state survey and certification agency, the state licensurc office, thc state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). k. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement). Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation ofproperty. See Attachment I (Center Supplement). m. The Resident Handbook. See Attachment J. n. Resident/Patient Rights. See Attachment K. o. Medicare/Medicaid information and display of' such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Cure's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-I and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of'personal items. See Attachment O. 7 s. ASM Form. See attachment P. t. Consent to Photograoh See Attachment Q. u. See Attachment R. v. See Attachment S. w. See Attachment T. x. See Attachment U. y. See Attachment V. z. See Attachment W. 4.05 Aosignment of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination, Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of' the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end ofthe day that the Agmission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Chan es in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of' this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature of Legal Representative, if signing on behalf of Resident: ~ ~'~'~ ~--~" ~"~"~)~--~"~L Date: /- ,~ ~- 0~ Signature of Legal Representative, signing on his/her own behalf: Date: SHERIFF'S RETURiq - REGULAR CASE NO: 2001-03280 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS GILBERT RUTH M ET AL BRIAN BARRICK , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon GIn~RT RUTH M the DEFENDANT , at 1003:00 HOURS, on the 4th day of June , 2001 at 940 WALNUT BOTTOM RD CARLISLE, PA 17013 by handing to RUTH M GILBERT a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: So Answers: Docketing 18.00 ~~~/~__~ Service 3.10 Affidavit .00 Surcharge 10.00 R. Thomas Kline .00 Sworn and Subscribed to before By: t ?/;~',~-~ ~t me this ,~ ? ?- day of Deputy Sheriff ~ _~;%r-. -~ ! A.D. ' Prothonotary ' ' / SHERIFF'S RETURig - U.S. CERTIFIED MAIL CASE NO: 2001-03280 P COMMONWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND HCR MANOR CARE VS. GILBERT RUTH M ET AL R. Thomas Kline , Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law served the within named DEFENDANT ,~AYWOOD GAIL E , by United States Certified Mail postage prepaid, on the 31st day of May ,2001 at 0000:00 HOURS, at 916 CORA ST JOLIET, IL 60435 , a true and attested copy of the attached COMPLAINT & NOTICE Together with ' The returned receipt card was signed by GAIL E HAYWARD on o61o7/2OOl Additional Comments: Sheriff's Costs: So answers: Certified Mail 5.68 R% Thomas Kline Affidavit .00 Sheriff of Cumberland County Surcharge 10.00 .00 21.68 Paid by WOLFSON & ASSOCIATES on 06/14/2001 Sworn and subscribed to before me this ~ ~ day ~! A.D. ! P~o~honotary , s · - SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2001-03280 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANOR CARE VS GILBERT RUTH M ET AL R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: GILBERT JOHN E but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of LANCASTER County, Pennsylvania, to serve the within COMPLAINT & NOTICE On June 14th , 2001 , this office was in receipt of the attached return from LANCASTER So answers .- .~ Sheriff's Costs: : Out of County 9.00 ' Surcharge 10.00 R.~ Thomas Kline Dep Lancaster Co 42.92 Sheriff of Cumberland County .00 67.92 06/14/2001 WOLFSON & ASSOCIATES Sworn and subscribed to before me this ~ ~ c~_ day of ~ g ~ ~rothonot a~¥ ~ · Complete items 1, 2, and 3. Also complete item 4 if Restricted Delive~J is desired. · print your ~ame and address o~ the mveme · Attach this ~ to the ~ack of the mailpiece, or on the front if space permits. [] No Gail E. ta~a~Cl 916 Cora 3oliet, IL 60435 [3 C.O.D. -- . .~_. PS Form 3811. Juh/~999 ~ome~Oc ' I Postage 8, Fees PaidJ / usPs / · Sender: Please print your name, address, and ZIP+4 in this box · CUMBERLAND COL~NTY .%~EP, IFF'S DEPARTMENT ONE COUIr{THOUSE SQUARE CARLISLE PA 17'013 I""lll"'llh',,,,th,ll,,,Ih,,Ih,,hh,lhhJ,,i,.h,hl,,~ SHERIFF'S OFFIC 50 NORTH DUKE STREET. P.O. BOX 83480, LANCASTER, PENNSYLVANIA 17608-3480 · (717) 299-8200 SHERIFF SERVICE PLEASE TYPE PROCESS RECEIPT, and AFFIDAVIT OF RETURN DO NOT DETACH ANY COPIES. I PLAINTIFF/S/ [-]cr ~'l.0r Cc~_i-e 2 COURT NUMBER 3 DEFENDANT/S/ ~ C';V~. Ruth N. Gilbert etal 5 NAME OF INDIVIDUA~E S/RV SERVE .~. ~'O]'1--~ ED G~][~E['t .... ED 6 Auo~te~S (Street or RFD. Ag&~,,,e,,; No. City. Boro. Twp. State and ZIP Code) AT L;;'~ St:. El.~abethtoem. L~ 17022 J~an~a~;te~- ~ ~Uml ~, r~., aD n o epu(ize the ' of County to execute this W ' et r d' to law. This deputation being made at the request and risk of the plaintiff. ~ 8.8PECIAI~ INSTRUCTION8 OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: CUMBERLAND CO NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or atlachmg a,~y properly under the parl of such deDuiy or the sheriff to any ~)lainliff herein for any loss. destruction or remOVal of any Such property before sherd/'s sale thereof. 9. BIGNATURE of AI'rORNEY or other ORIGINATOR 10. TELEPHONE NUMBER CUi"tBgRT.RND CO SEgRZFF LAW OFFICE OF WOLFSON & ASSOC 13. I acknowledge race,pi O~ BELOW F.O..R__USE OF SHERIFF ONLY -- DO NOT WRITE BELOW THIS LINE NAME o! Authofizod L.C90 Deputy o~ Cle~"---- ~ ~Hearlng date orcomplainta$indicaledabove.} ANNETTE WA~.TON 717-295-3609 .L 6/4/01 J 6/28/01 16. I hereby CERTIFY and RETURN that (~tave ;arsons ly sewed. [3 have legal evidence bi sew/ce as shown in "Remarks h "Rem-arks"thewril°rc°mpla'ntclescr~bLa~Onlhelndividual. coml~any corporation etc -'.~--,',' ....... '.[~ ave executed as shown n ~ooranon. etc.. al the acldress rose,ted below by hand~ng a TRUE and ATTESTED COPY I~ere~ ".,; .,,u,e=a Shown above or on the md~wdual, company, cor- 17. O I hereby certify and relurn a NOT FOUND because I am unable to locate the mchvidual, company, corporahon, etc.. named above. (See remarks below) 18 Name and bile of ~ndividual served (ii not shown above) (Relationship Io Delenclant--~--'--- 2~:d~rees~sn:f~w~e~::r~d(C~m~ete~n~y.~d~r~nt~han~h~wn~b~e~Sr~e~rRF~.A~a~mentN~c.~¥.B~r~.Tw~. 21. Dale f Sennce ;SHERIFF SERVICE PROCESS RECEIPT, end AFFIDAVIT OF RET~RN '9~~:'in ~r any J din po.s.on.a,er nob ,n y ng upon or altech,rig an . sl~Chon or m ---, .9. 81GNATURE of A~ORNE ~~R 'E OF SHERIFF 0 g TRUE~A~TEDCOPyl~t~,a;lhead~ressShown~arks,~have~xecufe~as , m_,. . or on ih. ,na,v,dual. com~h~W~o,~ HCR MANOR CARE, : IN THE COURT OF COMMON PLEAS Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA vs. : NO. 01-3280 CIVIL TERM RUTH M. GILBERT, GAIL E. : HAYWOOD and JOHN E. GILBERT : CIVIL ACTION - LAW Jointly and severally : Defendants : P~ELININARY OBJECTIONS TO COMPLAINT AND NOW, comes Defendant John E. Gilbert in the above captioned action, by and through his attorney Herschel Lock, Esquire, pursuant to Pa. R. Civ. P. 1028, and files the within Preliminary Objection to Plaintiff's Complaint, representing as follows: I. PI~ELIMINARY OBJECTION IN THE NATURE OF A DEMURRER FOR F/tILURE TO SET FORTH A CAUSE OF ACTION AGAINST DBrs~DANT JOHN E. GILBERT 1. Plaintiff, a health care provider, has pled that since January 29, 2000, through the date of the filing of its Complaint it provided Defendant Ruth M. Gilbert, a resident at one of its facilities, with residential health care service and treatment (Paragraph 6 of Plaintiff's Complaint attached hereto and marked as Exhibit "A"). 2. Paragraph 4 of Plaintiff's Complaint names John E. Gilbert as a Defendant in this action and Paragraph 5 thereof states "...that the invoices for his mother Defendant Ruth were forwarded to the home of Defendant John for payment of same." 3. As an Exhibit to its Complaint, Plaintiff attached the Admission Agreement between itself and Defendant Ruth Marie Gilbert (See Complaint's Exhibit B attached hereto). 4. Paragraphs 1.07 and 1.10 of said Admission Agreement, these entitled "Private Pay Resident" and "Primary Responsibility for Payment" respectively, deal with the issue of payment to Plaintiff for services it provided Defendant Ruth M. Gilbert, indicating that Defendant Ruth M. Gilbert is primarily responsible for the payment for those services which are not covered by other party insurance. 5. Paragraph 2.02 of said Admission Agreement, this entitled "Agreement to Make Payments on Behalf of Resident", states that a legal representative of resident Defendant Ruth M. Gilbert, this being Defendant Gail E. Haywood, "...agrees to promptly pay from resident's income and resources all fees and charges for which the resident is liable under this Agreement. The legal representative shall not incur personal liability on behalf of the resident except for a breach of the duty to provide payment from the Resident's income and resources ..." The Admission Agreement has on its last page the signatures of both Defendant Ruth Marie Gilbert and her legal representative Gall E. Haywood. 6. At no place on the Admission Agreement or any other document provided by Plaintiff in its Complaint is there shown the signature of Defendant John E. Gilbert. 7. Plaintiff's Complaint fails to plead any duty on the part of Defendant John E. Gilbert for payment for services Plaintiff provided to Defendant Ruth M. Gilbert and, instead, seemingly bases Plaintiff's assertions that he is responsible therefor solely because it mailed her bills to him. WHEREFORE, it is requested that this Court grant the Demurrer and dismiss the Complaint against Defendant John E. Gilbert for failure to allege a cause of action against him upon which relief may be granted. HERSCHEL LOCK, ESQUIRE 3107 N. Front Street Harrisburg, PA 17110 (717) 238-6661 Counsel for Defendant Supreme Court ID No. 22691 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR. MANOR CARE, : NO. Plaintiff : : vs. : CIVIL ACTION - LAW _. RUTH M. GILBERT, : GAlL E. HAYWOOD and : JOHN E. GILBERT : Jointly and Severally, : Defendants : COMPLAINT AND NOW, this.L]q day of !!i~,i ~ , 2001, comes the Plaintiff, HCR Manor Care, by and through ils attorney, Daniel F. Wolfson, Esquire, and the law firm of Wolfson 6~ Associates, P.C., and files the within Complaint and in support avers as follows: !. Plaintiff, HCR Manor Care (hereinafter referred to as "Plaintiff"), is a health care provider qualified to conduct business in the Commonwealth of Pennsylvania with offices and/or a place of business situate at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17315. 2. Defendant, Ruth M. Gilbert, hereinafter referred to as "Defendant Ruth"), is an adult individual with a last known address of 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013 2. Defendant, Gall E. Haywood, (hereinafter referred to as "Defendant Gall"), is an adult individual with a last known address of 916 Cora Street, Joliet, Illinois 60435. 2 Exhibit A 3. That Defendant Gall represented to be Legal Representative and/or Responsible Party for Ruth Fl. Gilbert. Defendant Gall is the daughter of Ruth M. Gilbert. 4. Defendant, John E. Gilbert, (hereinafter referred to as "Defendant John"), is an adult individual with a last known address of 517 High Street, Elizabethtown, Lancaster County, Pennsylvania 17022. 5. That the invoices for Defendant Ruth were forwarded to the home of Defendant John for payment of same. 6. That on or about January 29, 2000, through the present, Ruth M. Gilbert was a health care resident of Plaintiff, where she did receive various necessary residential health care services and health care treatment by Plaintiff. An itemization of said services is attached hereto, incorporated herein and collectively marked as Exhibit "A". 7. That on or about January 29, 2000, Defendant Gall, as Ruth H. Gilbert's Power of Attorney, executed an Admission Agreement which Agreement outlined various terms of residential health care services to be provided by Plaintiff and the Responsible party therefor. A true and correct copy of the Admission Agreement is attached hereto, incorporated herein, and collectively marked as Exhibit "B". 8. That Plaintiff submitted to Defendants a copy of the itemization of services accurately showing all debits and credits for transactions with Plaintiff. Said Statement of Account has been previously Identified as Exhibit "A" and incorporated herein by reference. 9. That Defendant s did not object to the above mentioned Statement of Account submitted by Plaintiff to Defendants. 10. As of Hay 2, 2001, the balance due, owing and unpaid on Ruth M. Gilbert's account as a result of said charges is the sum of Fifty-Four Thousand Two Hundred Thirty-Six and 42/100 Dollars ($54,236.42). See Exhibit "^" previously identified and incorporated herein. 11. Despite Plaintiff's reasonable and repeated demands for payment, Defendants have failed, refused and continue to refuse to pay all sums due and owing on Defendant Ruth's account balance, all to the damage and detriment of the Plaintiff. 12. Plaintiff has made numerous requests to Defendant Gall, as Legal Representative and/or Responsible Party, for Ruth M. Gilbert, demanding that the sums due and owing to Plaintiff be paid, and Defendant Gail, as Legal Representative and/or Responsible Party for Ruth kl. Gilbert, has ignored her fiduciary obligation to pay necessary and appropriate bills and obligations for her mother, Defendant Ruth.. 13. Plaintiff has made numerous requests to Defendant John, as a Responsible Party and as the person to whom all of Defendant Ruth's bills were sent, demanding that the sums due and owing to Plaintiff be paid, and Defendant John, as a Responsible Party of Defendant Ruth, has ignored his obligation to pay necessary and appropriate bills and obligations for his mother, Defendant Ruth. 14. Pursuant to Section i, Paragraph !.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay interest at a rate of eighteen percent (18%) per year on past due balances. See Exhibit "B" previously 4 identified and incorporated herein. 15. As of the date of the within Complaint, the amount of interest that has accrued on the past due balance Is the sum of Twelve Thousand Two Hundred Fifty- One and 50/100 Dollars ($12,251.50). ! 6. Plaintiff has retained the services of the law firm of Wolfson ~ Associates, P.C., in the collection of the amounts due from Defendants. 17. Pursuant to Section I, Paragraph 1.03, of the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed to pay reasonable attorney's fees and all court costs if the account is referred to an attorney for collection. See Exhibit "B" previously identified and incorporated herein. 18. As of the filing of this Complaint, Plaintiff has incurred reasonable attorney's fees from the law office of Wolfson ~ Associates, P.C., in the collection of the amounts due and owing by Defendants, incident to the within action, and Plaintiff shall continue to incur such attorney's fees throughout the conclusion of the proceedings in the amount of thirty percent (30%) of the principal balance due and owing to the Plaintiff by the Defendants. ! 9. That the amount of attorney's fees which represents thirty percent (30%) of the principal amount due and owing is the sum of Sixteen Thousand Two Hundred Seventy-One and 29/! O0 Dollars ($ ! 6,271.29). 20. Any and all conditions precedent to the bringing of this action have been performed by Plaintiff. 5 2 I. The amount in controversy exceeds the Jurisdictional amour~"~:e~q~'irJ-~- '- compulsory arbitration. WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this Honorable Court enter judgment in favor of Plaintiff and against Defendants, Gall E. Haywood and :John E. Gilbert for Ruth M. Gilbert, jointly and severally, in the amount of Fifty-Four Thousand Two Hundred Thirty-Six and 42/100 Dollars ($54,236.42), contractual Interest In the amount of Twelve Thousand Two Hundred Fifty-One and 50/100 Dollars ($12,251.50), reasonable attorney's fees in the amount of Sixteen Thousand Two Hundred Seventy-One and 29/i O0 Dollars ($16,271.29), the costs of this action and such other relief as the Court deems proper and just. Respectfully Submitted, WOLFSON &: ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-I 252 I.D. No. 206 ! 7 Attorney for Plaintiff 6 I I I III II I .. _ EXHIBIT PRIVATE JOHN GILBERT FOR RUTH GILBERT ROOM iQ0 -A $17 HIGH STREET Please Return TnlS Po~on ELIZABETHTOWN, PA 17022 With Your Paymen~ GILBERT, RUTH M 20013 05/07/00 02/28/01 ..qjE I CODEI SERVIOERENDERED I CHARGES FWD FROM PRECEDZNG STMT 32,964 48 31/00 AD3 EEC R & B/30 4,123 30/00 ADJ REC NON LEGEND lO 78 30/00 ADJ REC R ~ B 30 3,990 31/00 AD3 REC LEGEND 550 24 31/00 ADJ REC NON LEGEND 139 74 21/00 ADJ REC R & B 31 4,123 30/00 ADJ REC LEGErlD 159 68 30/00 ADJ REC r4o. LEGEND 9 30/00 ADJ REC ~OUND TREATMENT 48 O0 30/00 AOJ REC R & B 30 3,990 09 31/00 ADJ REC R & B 31 ~,123 31/01 ROi CABLE RENTAL 5 00 PAYMENT DUE BY THE LOTH OF THE MONTH 54,236.42 AMOUNT DUE JOHN GILBERT PRIVATE fOR RUTH G~LBERT ROOM 100 -A 517 HIGH STREET ELIZABETHT0~N, PA 17022 PleaseReturnT~lsPon,on V/llh Your Payment G'ZLBERT,, RUTH F, 20013 05107/00 02/28/01 ~',/ic E CODE SERVICE RENDERED CHARGES CREDITS /01/01 BALANCE FORWARD 8,004.50 /01/01 11100 BEAUTY S~ib NASH 1/18 ( OTY I 9.00 /01/O1 11100 BEAUTY SHOP WASH 1/25 ( QTY 1 9.00 /01/01 11100 BEAUTY AND BP, RBER ( OTY i 9.00 :01/01 11100 BEAUTY W & S 1/4 ( OTY 1 9.00 '01/01 11100 BEAUTY !,J & S 1/i! ( OTY 1 9.00 ,=8/01 11600 CABLE RENTAL ( OTY i 5,00 /13/01 29001 PHARP, ACY LEGEIqD ( OTY i 293.17 /05/01 30001 PHAR,~IACY NON LEGEND ( OTY I !0.00 '28/01 51501 WOUND TREATP, ENT ( OTY 56 448.00 .'07/01 11100 BEAUTY AND BARBER ( OTY i 9.00 ~15/01 11100 BEAUTY AND BARBER ( OTY 1 9.00 ~01-02/28/01 RO0~ CHARGE ,1,123.00 ~01-03/31/01 ADV ROOf; CHARGE 4,123.00 SUB TOTALS 17,069.67 CARRIED FI4D AMOUNT DUE .. I GRRLTSLE. PA 17013 PABE 2 (7 J. 7)-249-0085 `30HN GILBERT PRIVATE FOR RUTH GILBERT RO0~ 100 -A 517 HIGH STREET ELIZABETHTOWN. PA 17022 PJeaseRe[umThisPo~lon W~t~ Your Paymen[ GILBERT, RUTH M 20013 05/07/00 02/28/01 -~RV~CE CODE SERVICE RENDERED ! CHARGES CREDITS FbJD FRO~I PRECEDING ST,'IT 17,069.67 /31/00 AD3 REC LEGEi',/"D 124.94 /31/00 ADO RED NON LEGEND 7.95 /31/00 ADJ REC [JOUND TREATr~ENl' 464.00 /31/00 AD:~ RED R & B 6 798.00 /31/00 AD`3 RED R & B 25 3,325,00 /31/00 AD,3 REC NON LEGEND 3.39 /31/00 AD`3 RED R & B 25 DAYS 3,300.00 /30/00 AO3 REC NON LEGEND 2.65 /30/00 ADS EEC R & B 22 2,904.00 /30/00 AD3 RED R .r, B 8 1,016.00 /31/00 AD3 REC NON LEGEND .90 /31/00 AD`3 REC R & B 31 3,937.00 /31/00 AD3 REC NON LEGEND 10.98 SUB TOTALS 32,964.48 CARRIED AMOUNT DUE EXHIBIT "B" .ADMISSION AGREEMENT This Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities of the panics with respect to the Resident's stay at this HCR Manor Cafe's Health Care Center ("Center"). I'-eg,qRepre, entative: ~'~L~/~'~/~..~ d/dixie_' Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGlq'TS AND RESPONSIlllI, ITIES OF TItE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (10~) day of each month. '~'he Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section -~hall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care Organization (see Section 1.06). ' 1.02 ~. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of' Care. The Center reserves the right to charge for perso.,nal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along Mth the Room and Board Rate by the tenth ( 10~') day of' the mo nth. subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 ln_.~pendent Providers. The Resident shall be directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of' the program. 1.05 Governmental Pro,rams. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center shall accept pa)nnents under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for an)' co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay ~:esidents The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: t/Medicare, ~'ledicaid and/or VA. Medicare ma)' pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered se~ices according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take su~ legal action as necessary, including requesting a court to order such payment. 1.06 Third Party ?avors and Managed Care Or~,anizations. Ifa Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("?PO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate tinily in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (5~ days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative ac'knowledge that if they fail to provide such information, they may be responsible for any denied charges due to tack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Auplication for Benefits. It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private in~rance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This 3 Representative that semites provided at the Center may not be covered by a governmental payor, lhkd p~y p~yor o~ managed ca~e organization. The Res[den[ ~n~or ~ega[ ~eprese~t~t[ve agrees to be responsible ~o~ non-covered se~kes. A price list o~ se~'~ces is always available at ~he business o~ce upon request. 1.11 Personal Physician The Resident has the right to choose a personal physk[an, provided tMt the physician selected [~ properly lkensed and agrees to abide by applicable law and the ~les ~nd policies of the Center. At lhe time o~ ad,ss[on, the ~esident must supp]y the Cenler wkh the n~me o~h[~er personal physk[~n. I~t~e ~es[dent changes physicians at ~ny time ~er admission, the Resident and/or ~egal Representative must immediately not[~ the Center the new physician's name. I~ the physician chose~ by the ~es~dent f~[ls ~o provide ~eeded coverage and attendance or fa~ls to ~bide by applkable laws ~d regulations, the Center shall have the ~ght to call ~nother physician to attend the ~es[dent and the ~ees charged by such sh~ll be borne by lhe Res[dent. 1.12 PMrmacv. The Resident and/o~ Legal Representative acknowledge the right to choose a pM~acy o~ choice, provided the pharmacy selected is properly licensed, packages ~nd supplies pMrmaceuficals in accordance with State law and agrees to abide by the Center's policies ~nd procedures and ~he pharmacy has a medication distribution system similar to the Center's anc[lla~ pM~acy's medication distribution system. ~G~TS AND ~SPO~S~I~' O~ T~E ~EGA~ ~P~SENTATI~ 2.01 Legal Authority. The ~ega] ~epresenta~[ve hereby represents that ~e/she h~s access to the Kcs[dent's income or resources ~nd th~c ~he documents supposing suc~ authorky, any, Mve been delivered to t~e Center. 2.02 A~reeme~t to Make Payments o~ Behal~0~Kes[dent. The Legal Representative ~grees to p~y promptly ~rom the ~es[deat's income or resources ~[1 fees and charges for w~k~ Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the ~esident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and charges provided for in this Agreement. 2.03 Requested Items. The Lega~ Representative shall be personally liable for any se~'ices or products specifically requested by the Legal Representative to be supplied to the Resident, unless such semites or products are covered by a gove~ental program. 2.04 Exhaustion oFResident's Funds. If the Resident's financial resources change such that the ~esident may be eligible for Medicaid, the Resident an&or Legal Representative must noti~ the Center in writing when the application for Medicaid is made. If the Legal Representative fails to noti~ the Center in ~iting or fails to file for Medicaid in a timely and proper ma~er, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which othe~,ise would have been covered had application been made in a timely and proper manner. Legal Representative shall provide such information about the P,.esident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Uoon Discharae. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Resnonsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. III. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center shall ~rnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of'care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deoosit. The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center ~vithin thirty (30) days after disch~.rge or transfer or within the time frame required by State law. In the ease of Medicaid Residents, any such refund shall he paid within thirty (30) days of the Center's receipt of'the final Medicaid payment for care of' the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: C~nter personnel, attending physicians and consultants; and person, firm, government entity, third party payor or managed care organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance facility or provider to whom or which the Resident ma>' be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of, the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of'the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of, medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of.good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf, of, the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Repres6ntative hereby consents on behalf of,the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of, Resident for use in identifyin~ the Resident, f,or placement of the photograph in the Medication Administration Record or other records and for any other similar uses of' the photograph for Center and staff to identify the Resident. 4.04 'Notice of, Services, Policies and Additional Inf,ormation The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of'the items or policies and procedures, if'applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of, Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security AdminiStration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. f. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of, such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds 6 g. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). h. Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). i. Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). j. The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). k. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement). Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. See Attachment I (Center Supplement). m. The Resident Handbook. See Attachment J. n. Resident/Patient Rights. See Attachment K. o. Medicare/Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-1 and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. s. ASM Form. See attachment P. t. Consent to Photograph See Attachment Q. u. See Attachment R. v. See Attachment S. w. See Attachment T. x. See Attachment U. y. See Attachment V. z. See Attachment W. 4.05 Assignment of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination, Discharee and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the A~lmission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property 8 or' [ny'person or entity (includins thc Ce~er~, ~'~)t t'r[ thi="-ias¢'oc ni~ll~enc~ o( tho center's employees and agents. 4.08 Chan~es in the Law. ~y provision of the Agreement that is found to be invalid or une~orceable as a result of a change in State or ~edera{ law will not invalidate the remai~ng provisions of this Agreement and, it is agreed that to the e~ent possible, the Resident and the Center will continue to ~lfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature of Legal Representative, if signing on behalf of Resident: Signature of Legal Representative, signing on his/her own behalt2 Date: Center Repr.sentative: ~ ~t~ [J./5}Y'ltt_[)[l~,/],~"~/~ Date: /'~ ~ ~'~ IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA HCR MANOR CARE, : NO. 01-3280 Plaintiff : vs. : CIVIL ACTION - LAW RUTH M. GILBERT, : GAlL E. HAYWOOD and : ]OHN E. GILBERT : ]omdy and Severally, : Defendants : PRAECIPE TO DISMISS COMPLAINT WITHOUT PRE1UDICE TO THE PROTHONOTARY: Please dismiss the above-captioned Complaint without preludlce. Respectfully submitted, WOLFSON 6~ ASSOCIATES, P.C. 267 East Market Street York, PA 17403 (717) 846-1252 ID No. 20617 Attorney for Plaintiff Dated: July 17, 2001