HomeMy WebLinkAbout01-3295 IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, : NO. ~::~1 --
Plaintiff, :
:
vs. : CIVIL ACTION - LAW
:
VIOLET 1,1. TROUT, Individually, and :
G. FRANKLIN EICHELBERGER, Individually, :
and for VIOLET 1,1. TROUT, :
Defendants. :
NOTICE
You have been sued Jn Court. If you wish to defend against the claims set forth in the following
pages, you must take action within twenty (2.0) days after this Complaint and Notice Is served, by
entering a written appearance, personally of by attomey, and filing In waiting with the Court your
defenses or objections to the claims set forth against yOU. You are warned that If you fail to do so, the
case may proceed without you and a judgment may be entered against you by the Court without further
notice for any money claimed In the Complaint, or 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 DO 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 pagJnas, sigulentes, used tiene viente (20) dias de plazo al partlr de la fecha de lademanda y la
notlflation. Used debe presentar una al~ariencia escrita o en persona o pot abogado y archivar en la
cone en forma escrita sus defensas o sus objeclones a last demandas en contra de su persona. Sea
avisado clue si used no se defienda, la cone tomara medidas y I~sedldo entrar una orden contra used sin
previo aviso o notificaclon y pot cualquJer queja o allvio clue es pedldo en ia peticlon de demanda.
Used puede perder dlnero o sos propledades o otros derechos Jmportantes para used.
LLEVE ESTA DEMANDA A UN ABODOAGO IMMEDIATAMENTE. SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO
VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION
SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR
ASSITANCIA LEGAL.
Lawyer Referral Service
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. o/-
Plaintiff, :
:
vs. : CIVIL ACTION - LAW
:
VIOLET M. TROUT, Individually, and :
G. FRANKLIN EICHELBERGER, Individually, :
and for VIOLET M. TROUT, :
Defendants. :
COMPLAINT
AND NOW, this~,~L/ day of ~ , 2001, comes the Plaintiff,
HCR Manor Care, by and through its attorney, Daniel F. Wolfson, Esquire, and the law
firm of Wolfson ~z Associates, P.C., and flies the within Complaint and in support avers
as follows:
I. PlalntJff, HCR Manor Care (hereinafter referred to as PlaintJff), 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 ! 70 ! 3.
2. Defendant Violet M. Trout, (hereinafter referred t oas "Defendant
Violet"), is an adult Individual with a last known address of 940 Walnut Bottom Road,
Carlisle, Cumberland County, Pennsylvania ! 7013.
3. Defendant, G. Franklin EJchelberger, (hereinafter referred to as
"Defendant Frank"), Is an adult individual with a last known address of 32 South
Hanover Street, Carlisle, Cumberland County, Pennsylvania i 7013.
4. That Defendant Frank represented himself to be Power of Attorney for
Defendant Violet. Defendant is the nephew of Violet kl. Trout. A true and correct
copy of the General Power of Attorney whereby Violet kl. Trout designated G.
Franklin Eichelberger as her lawful Power of Attorney is attached hereto, incorporated
herein, and collectively marked as Exhibit "A".
5. That on or about May 28, 1999, through the present, Defendant Violet
was a health care resident of Plaintiff, where she did receive and where she continues
to receive various necessary residential health care services and health care treatment
by PlalntJff. An itemization of said services is attached hereto, incorporated herein and
collectively marked as Exhibit "B".
6. That on or about Hay 28, 1999, Defendant Frank, as Defendant
Violet's Power of Attorney and Responsible Party, 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 "C".
7. That Paragraph four (4) of the Admission Agreement did describe the
various responsibilities of Defendant, which responsibilities did Include payment for the
daily rate and charges for supplemental services, supplies not paid by any third party,
as well as applicable co-insurance and deductibles and all expenses of discharge or
transfer. See Exhibit "C".
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 "B" and incorporated
herein by reference.
9. That Defendants did not object to the above mentioned Statement of
Account submitted by Plaintiff to Defendants.
I 0. As of April 23, 2001, the balance due, owing and unpaid on Defendant
Violet's account as a result of said charges is the sum of One Hundred One Thousand
Five Hundred Sixty-Five and 77/100 Dollars ($101,565.77). See Exhibit "A".
il. Despite Plaintiff's reasonable and repeated demands for payment,
Defendants have failed, refused, and continues to refuse to pay all sums due and owing
on the outstanding account balance, which accrued due to residential health care
services provided to Defendant Violet, all to the damage and detriment of the Plaintiff.
12. Plaintiff has made numerous requests to Defendant Frank, as Power of
Attorney and Responsible Party for Defendant Violet, demanding that the sums due
and owing to Plaintiff be paid, and Defendant Frank, as Power of Attorney for
Defendant Violet, has ignored his fiduciary obligation to pay necessary and appropriate
bills and obligations for Defendant Violet.
4
13. That Defendant Frank has also been uncooperative in providing the
necessary information to Plaintiff to assist Plaintiff in completing an application for
Medical Assistance on behalf of Defendant Violet.
14. Pursuant to Paragraph eight (8) of the Fee Schedule which was attached
to 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 "C".
15. Plaintiff has retained the services of the law firm of Wolfson ~z
Associates, P.C., in the collection of the amounts due from Defendants.
! 6. 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.
17. That the amount of attorney's fees which represents thirty percent
(30%) of the principal amount due and owing is the sum of Thirty Thousand Four
Hundred Sixty-Nine and 73/100 Dollars ($30,~[69.73).
18. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
5
19. 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, Violet
M. Trout, Individually and G. Franklin Elchelberger, Individually and for Violet M.
Trout, in the amount of One Hundred One Thousand Five Hundred Sixty-Five and
77/100 Dollars ($101,565.77), reasonable attorney fees in the amount of Thirty
Thousand Four Hundred Sixty-Nine and 73/100 Dollars ($30,469.73), the costs
of this action and such other relief as the Court deems proper and just.
Respectfully Submitted,
WOLFSON ~z ASSOCIATES, P.C.
267 East Market Street
York, PA 17403
(717) 846-1252
I.D. No. 20617
Attorney for Plaintiff
6
EXHIBIT "A'
GENER~I'. PO~ER OF A~ORNE¥
KNOW ALL MEN BY THESE PRESENTS, that I, VZOLBT M. TROUT, of 304 Center
Street, Frederick, Maryland 21701, do hereby constitute and appoint G.
FRANKLIN EICHELBBRGER, of 924 Alexander spring Road, Carlisle, Pemlsylvania
17013, my true and lawful general Attorney-In-Fact for me, and generally in
my name, place and stead=
1. To enter upon and take possession of any land, buildings, tenements
or other structures, or any part or parts thereof, that may belong to me, or
to the possession whereof I may be entitled.
2. To ask, collect and receive any rents, profits, issues or income of
any and all such lands, buildings, tenements or other structures~ or of any
part or parts thereof.
3. To make, execute and deliver any deeds, mortgages or leases, whether
with or without covenants and warranties, in respect of any such lands,
buildings, tenements or other structures, or of any par~ or par~s thereof,
and to sell and manage any such lands and to manage, repair, alter, rebuild
or reconstruct any buildings, houses or other structures, or any par~ or
parts thereof, that may now or hereafter be erected upon any such lands.
4. To demand, sue for, collect, recover and receive any goods, claims,
debts, monies, interest and demands ~hatsoever now due or that may hereafter
be due or belong to me (including the right to institute any action, suit or
legal proceeding for the recovery of any land, buildings, tenements, or other
structures, or any part or parts thereof, to the possession whereof I may be
entitled), and to make, execute and deliver receipts, releases or other
discharges therefor, under Seal, or otherwise.
5. To make, execute, endorse, accept and deliver any and all bills of
exchange, checks, drafts, notes and trade aoceptancee~ to execute any and all
income tax returns, Social Security applications and applications for pension
and retirement benefits and disability benefits of every nature, and any and
all other instruments, papers and documents as my Attorney-In-Faotshsll deem
necessary or appropriate~ and to enter any safe deposit box in any ba~ and
to withdraw therefrom any and all prope~y therein contained belonging to me.
6. To pay all sums of money, at any time, or times, that ~ay hereafter
be owing by me upon ~ny bill, account, or any bill of exchange, check, draft,
note.or trade acceptance, made, executed, endorsed, accepted and delivered by
me, or for me, in my name, by my said Attorney-In-Fact.
7. To defend, settle, adjust, compound, submit to arbitration and
compromise all actions, suits, accounts, reckonings, claims and demands,
whatsoever, that now are, or hereafter shall be, pending between me and any
person, firm or corporation, in such manner and in all respects as my
Attorney-In-Fact shall think fit.
8. To hire accountants, attorneys-at-law, clerks, workmen and others
and to remove them, and appoint others in their place and to pay and allow to
the persons to be so employed such salaries, wages, or other remunerations,
as my Attorney-In-Fact shall thin~ fit.
9. To enter into, make, sign, execute and deliver, acknowledge and
perform any contract, agreement, writing, or thing that may, in the opinion
of my Attorney-In-Fact be necessary or proper, to be entered into, made or
signed, sealed, executed, delivered, acknowledged or performed~ and
especially should I suffer any illness or accident, physical or mental,
requiring hospitalization or the use of a convalescent home should my present
3
residential provisions be inadequate, then I do hereby empower my Attorney-
In-Fact to make ell arrangements necessary and proper, in hie 8olo Judc~nent,
to place me in a hospital or convalescent home, executing the necessary
agreements or contracts therefor, and to pay all bills and expenses which'
might be incurred, all to the exclusion of any authority over my person or
property by any other person or relative.
10. To buy, receive, lease, accept or otherwise acquire, and to sell,
transfer, pledge, mortgage, hypothecate or 9therwise encumber or dispose of,
any property whatsoever and wheresoever situate, be it real, personal, mixed
and/or intangible, upon such terms as my Attorney-In-Fact shall think proper~
and, in general, to borrow on my behalf, any and all sums of money that my
Attorney-In-Fact shall determine necessary or appropriate in connection with
the management of my affairs.
11. To sell, contract to sell, deed, convey or otherwise dispose of any
and all real estate that I may own, wherever situate; including especially
that real estate that I own located in the City of Frederick, Frederick
County, Maryland, and being known as 304 Center Street, Frederick, Maryland
21701, and in connection with these powers, specifically, I do hereby grant
unto my Attorney-In-Fact the right and power to sign, seal, execute,
acknowledge and deliver any and a}l instruments in writing of any kind and
nature, as may be necessary or convenient, containing such terms and
conditions as my Attorney-In-Fact may deem advisable, to completely and
effectually complete final settlement under any contract of sale which my
Attorney-In-Fact shall deem appropriate for the sale of any and all of my
real estate, and my Attorney-In-Fact in connection with any such sale shall
have the right to receive full proceeds coming to me as a result of said
4
sale, without the necessity of the purchaser or settlement officer to see to
the disposition of the settlement proceeds or the proceeds of any such sale.
12. Under the terms hereof, I do specifically grant unto my. Attorney-
In-Fact the power to borrow on my behalf any and all sums of money that my
Attorney-In-Fact shall deem necessary end/or appropriate~ and in connection
therewith, I do hereby specifically grant unto my Attorney-In-Fact the power
to collateralize any such loan with any and all of my proper~y of wherever
nature and description and wherever situate.. Additionally, I do specifically
grant unto my Attorney-In-Fact the power to purchase in any amount that my
Attorney-In-Fact shall deem appropriate, United States Treasury bonds, bills,
notes or other obligations, redeemable at par, in payment of any and all
Federal Estate taxes that might arise upon my death, with such United States
Treasury obligations being more popularly known as "Flower Bonds".
13. Intending to grant unto my Attorney-In-Pact full power of
substitution, I do hereby grant unto my Attorney-In-Fact the power to
constitute and appoint, in his place and stead, as his substitute, one
attorney, or more, for him, with full power of revocation vested in my
Attorney-In-Fact.
14. Without, in anywise, limiting the aforegoing, I do grant unto my
Attorney-In-Fact the power general&y to do, execute and perform any other
act, deed, matter or thing, whatsoever, as fully and effectually as I could
do, if personally present~ and it is my intention and purpose in executing
this Power of Attorney to grant unto my Attorney-In-Fact the complete power
and authority to bind me in any manner or form by any written and/or oral act
or deed as fully and completely as I myself could do if I were personally
present and acting.
15. This General Power of Attorney shall not be affected by my
disability, and I request that no guardianship proceeding for my property be
commenced in the event of my disability~ but in the event any court appoints
a guardian for my person and property, I direct that my Attorney-In-Fact, G.
Franklin Eichelberger, or his appointed substitute or substitutes, shall
serve as guardian, without bond.
16. This General Power of Attorney shall not be construed by any court
of law or by any other entity or person as a grant unto my Atto~lley-In-Faot
of a general power 9f appointment, and in the use of this General Power of
Attorney my Attorney-In-Fact is prohibited from dealing with any of my
property for less than valuable considaration.
And I, the said Violet M. Trout, do hereby ratify and confirm all
whatsoever my said Attorney-In-Fact, or his substitute or substitutes, shall
do, or cause to be dgne, in, or about the premises, by virtue of this Gener&l
Power of Attorney.
IN WITNESS WHEREOF, I have hereunto set my hand and seal, in the County
WITNESS:
~Violet M. Trout
EXHIBIT "B"
HANORCARE CARLISLE 372
940 NALUUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
PRIVATE
FRAr~K ETCHELBERGER
/.FOR VIOLET TROUT ROOf1 165 -A
32 S. HANOVER ST. APT. 2
CARLISLE. PA 17013 Please Return Thi~ Porhon
Wlln YOUr Payment
T.I%(~ U,T,, VZOLET 98139 06/29/99 03./31/01
SERVICE CODE 1. SERVICE REHDERED ~'~"~3-~'S i CREDITS
~ / O.L/03. BA L AN CIi'--'FORI, JA]~O' 86,866.3.3: --'
0]./12/01 30009 PHARMACY I'~OI',ILEG/ND QTY i ) 13.83
01/21/01 51501 t, JOUt~O TREATilEI'4T OTY 11 ) 88.00
01]31/01 51801 TOTAL It;COt,~T-DLY FEE QTY 31 ) 93.00
01/31/01 53101 NUBASTC ,aUTCE BERRY .1.63 OTY 124 ) 163.68
01/31/01 5;i"201 NTRTNL/ENTRL SERV 6RP 3 0,TY 93 ) 372.00
01/09/61 29,~09 pHP/RlflACY~_LEGEND (~TY. _1 ) 101.62
PAYMENT OUE BY THE
lOTH OF THE
91,562.2'
AMOUNT DUE
./
MANORCARE CARLISLE 372
940 WALNUT BOTTOH ROAD
CARLISLE, PA 17013
(717)-249-0085
FRANK EICHE'LBERGER PRIVATE
F'OR VIOLET TROUT RO0~ 165 -A
32 S. HANOVER ST. APT. 2
CARLISLE, PA 17013 PleaseReturnThisPod~on
W~lh Your Payment
TROUT VIOLET
, 98139 06/29/99 02/28/01
r DATE OF
~2/01/0~ BALANCE FORNARD 9~,562.26
~2/~/~ [[[eO BEAUTY [4 ~ S ~/~6 ( ~TY [ 9.~0
02/~[/~1 11lee BEAUTY PERH 1/23 ( QTY ~ 36.9~
~2/8~/0~ ~ BEAUTY N & S [/3~ ( ~TY [ 9.eO
02/~1/0[ [[lOe BEAUTY '~J ~ S ~/~2 ( ~TY
~2/~/~1 1~10~ BEAUTY N & S [/09
02/06/~1 29001 PHARMACY LEGEND ( OTY ~ 107,91
~2/~5/~1 5~501 NOUr4D TREATHENT ( QTY 8 64.00
~2/28/e~ 5~8~[ TOTAL [NCONT-OLY FEE ( QTY 28
e2/28/0[ 53[e[ NUBAS[C 3U[CE BERRY 163 ( OTY [12 [47,84
0'2/28/el 53201 NTRTNL/ENTRL SERV GRP 3 ( OTY 84 336.ee
~2/23/01 3~01 PHARHACY NON LEOE/~D ( OTY [ [~.87
~2/05/01 11100 BEAUTY A/lO BARBER ( OTY 1
~2/13/~1 111~0 BERUTY AND B~RBER ( ~TY 1 9.00
SUB TOTALS 92,402.88 .¢.
CARRIED FI.
AMOUNT DUE
HANORCARE CARLZSLE 372
940 WALNUT BOTTOH ROAD
CARLISLE° PA 17013
(717)-249-0085
FRANK EzCHELBERGER pRTVATE
FOR VZOLET TROUT RO011 165 -A
32 S. HAi'~OVER ST. APT. 2
C A R L T S L E, P A 17013 Please Return This Portion
Wi~h Your P. aymen~
...... o5/2o/99 o3/31/ol
DATE OF
03/01/01 BALANCE FORWARD 96,Bll.38
83/85/01 51501 t4OUND TREATHE[~T ( QTY 5 ) 40.00
03/31/01 51801 TOTAL ItJCONT-DLY FEE ( QTY 31 ) 93.00
03/31/01 53101 NUBASZC 3UZCE BERRY 163 ( QTY 124 ) 163.68
03/31/01 53201 rJTRTNL/ENTRL SERV GRP 3 ( QTY 93 ) 372.00
B3/25/01 30001 PHARHACY NOr4 LEGEtJD ( QTY i ) 13.71
03/07/0! 11100 BEAUTY Ar4D BARBER ( QTY i ) 9.05
53/13/01 11100 BEAUTY AND BARBER ( QTY I ) 9.00
03/20/01 11100 BEAUTY At~D BARBER ( QTY I ) 9.00
03/27/01 11100 BEAUTY A~4D BARBER ( QTY I ) 9.00
03/01/01 REV LAST HO RC 4,123.(
03/01-03/31/01 ROOH CHARGE 31 DAYS AT 138.00 ~,278.00
04/01-04/30/01 AOV ROOH CHARGE 30 OAYS AT 138.00 4,140.00
52/28/01 AD3 CORRECT R&B FOR 2/01 ~,123.¢
SUB TOTALS 105,947.77 8,246.(
CARRZED Ft.
AMOUt~TDUE
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013 PAGE 2
(717)-249-0085
PRIVATE
FRANK EICHELBEROER
FOR VIOLET TROUT ROOM 165 -A
32 S. HANOVER ST. APT. 2
Please Return Th~s Potion
CARLISLE, PA 17013 WithYourPaymenl
TROUT, VIOLET 98139 06/29/99 03/31/01
DATE OF
S~RViCE I CODE I SERVICE RENDERED I CHARGES I CREDITS
FWD FROM PRECED[rlG STMT 105,947.77 8,246.0~
~2/28/01 AD3 CORRECT R&B FOR 2/01 3,864.00
PAYMENT DUE
UPON RECEIPT
101o565.7;.
AMOUNT DUE
EXHIBIT "C"
ONTRACT BETWEEN PATIENT/RESIDENT AND FACILIT Health Services
~'I'HIS ADMISSION AGREEMENT (the "Agreement") is entered into this 2°0 ~ ~ _ ...r .~ c day of'
(7'1. c~ ~./ ,19 C~c~ ,between /~/~trtOc COJ~ ~O./d.~ ~t~l~""F~E~lity"),and
V'I Ol~d~/ "J--r-O cL--f- (the "Patient/Resident"), and/or
(the "Responsible Party"). As used herein, the term "Patient/Resident" shall also mean the Responsible
Party, if any. The parties agree as follows:
1. Commencement. This Agreement shall begin on the date of admission of the Patient/Resident
to the Facility.
2. Termination of Agreementr Discharge and Transfer.
a. Termination by Patient/Resident The Patient/Resident may terminate this Agreement by
giving the Facility at least five (5) days advance written notice. The Patient/Resident is responsible
for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually
leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending
physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and
Responsible Party agre.e to assume all responsibility for injury or harm to the Patient/Resident, and
hereby release the Facility, its employees and agents, from all liability connected with such departure.
b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat-
ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Residenrs needs
cannot be met; (2) the Patient/Resident presents a danger to th~ health or safety of other indivi-
duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the
Patient/Residenrs health has improved sufficiently so that the Patient/Resident no longer needs the
services provided; or (5) the Facility ceases to operate. However, the Patient/Resident may be
transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or
discharge is required due to the Patient/Residenrs medical needs; (2) the Patient/Resident presents
a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not
resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The
Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Residenrs right
to appeal a discharge decision with State authorities and the appeals process. If this Agreement is
terminated and/or the Patient/Resident is discharged by the Facility, the Responsible Party agrees
to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate
the Patient/Residenrs discharge.
3. Responsible Party. The Patient/Resider~t shall execute Exhibit A regarding Responsible Party
appointment.
4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and
charges for supplemental services and supplies not paid by any third party as described in the Fee
Schedule, attached as Exhibit B, as well as applicable co-insurance and deductible amounts and all
expenses of discharge or transfer.
,5. Release of Information. The Patient/Resident hereby authorizes all persons and/or entities to
release all or any part of his/her medical/health records to the Facility. The Patient/Resident also
authorizes the release of records or information to any health care institution to which the Patient/
Resident may be transferred, any provider involved in the care of the Patient/Resident, any third
party payor, including, but not limited to, government and private insurers, or any other person entitled
or authorized to receive such information by law or by the Patient/Resident.
MHC-OOe-lO (Rev. 7/96) pg3 1 of 3
i~~ ..
Conditions (collectively referred to as "Conditions")
1. The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred by
the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth
in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the prevision of
personal clothing and care supplies as needed or desired by the Patient/Resident and as
required by the Facility.
2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other
property of the facility, other Patient/Residents or employees of the facility damaged by the
Patient/Resident.
3. All of the information, including but not limited to that contained on the attached Apphcatlon
for Residency, dated -'~3~u_ ~? ,199 ~'~ , and which is attached hereto and
made part of this Exhibit al~ of the Admission Agreement, is true and accurate as of this
date and all assets listed in the application are in fact available to the Patient/Resident for
the Patient/Resident's cam while at the facility.
4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other-
wise transfer the' Patient/Resident's assets and/or assets which are available for the Pat-
lent/ Resident's care so as to prevent such assets from being used to pay for the care of
the Patient/Resident while at the facility.
5. When the assets available to pay for the Patient/Resident's care at the Facility are not
sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident
will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and
other documents necessary or advisable to qualify him/her for all third party payor programs
for which he/she may be eligible, including Medicaid.
6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/
Resident will provide financial information regarding monthly credits, increases and decreases
in the Patient/Resident's bank account(s) and other assets to the Facility to enable the
Facility to provide requested data to Medicaid representatives.
7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident
will be utilized to pay extra charges ri,ct covered by the third party payor in a timely manner,
and to notify the administrator of the Facility of any problem anticipated in paying such charges.
The undersigned understands and acknowledges that the Facility is relying upon the above Conditions
in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above
warranties and representations are no! true, or if. the abov~ ~ovenants an.d. agreements are not
complied with, the Facility will have detrimentally relied upon.~tfl~fn and_.~the Facility will suffer financial
Responsible P~r['~-~ Signature ~ -- ~
Reap~ar ty --
MHO.OOa40 (Rev. 4196) PO ? 2 of 2
· Federal Resident Rights · Barber/Beauty Services
· Resident Responsibilities · Mail Policy
· Life Sustaining Treatment Policy · Voting Materials
· Medical/Nursing Education · Photo/Media Events
· Dental, Vision and Hearing Services · Personal Fund Account Procedure
· Interdisciplinary Care Conference · Tobacco Policy
· Utilization Review Meetings (if applicable) · Grievance Procedures
· Personal Laundry Policy · State Resident Rights (if applicable)
14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN
ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS
LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW
SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH
ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH
AMENDMENTS SHALL BE A PART OF THIS AGREEMENT.
15. Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors,
administrators, helm, beneficiaries, and assigns. The waiver by either party of any breach or 'default
of this Agreement shall ~ot operate as a waiver of any subsequent breach or default. The provisions
of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not
affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the
entire agreement and any changes shall be in writing and signed by both parties.
IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day
and year above written. ~
Facility Representative - b-Tgnature
Facility Representativ~ -~rln~(~d Name & Title Ree~ns_Jb,y'~rty.~-/Printed Name
im~.oea.ao (Rev. 4/06) Pa 6 3 of 3
SHERIFF' S RETURN - REGULAR
CASE NO: 2001-03295 p
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
TROUT VIOLET 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
TROUT VIOLET M
the
DEFENDANT , at 1011:00 HOURS, on the 4th day of June , 2001
at 940 WALNUT BOTTOM ROAD
CD~RLISLE, PA 17013 by handing to
VIOLET TROUT
a true and attested copy of COMPLAINT & NOTICE together with
and at the same time directing ~er attention to the contents thereof.
Sheriff,s Costs: So Answers:
Docketing 18.00
Service 6.20 ~~~/,/~
Affidavit .00
Surcharge 10.00 R. Thomas Kline
.00
34.20 07/06/2001 ~
WOLFSON & ASSOCIATES
Sworn and Subscribed to before By: ~ ~,
me this /~-- day of Deputy Sheriff
C~.. ~L~3~ A.D.
~P~othonotary ' ~'
SHERIFF'S RETURN - NOT FOUND
CASE NO: 2001-03295 P
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF CUMBERLAND
HCR MANOR CARE
VS
TROUT VIOLET 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
inquiry for the within named defendant, DEFENDANT
EICHELBERGER G FRANKLIN but was
unable to locate Him in his bailiwick. He therefore returns the
COMPLAINT & NOTICE
, NOT FOLR~-D , as to
the within named DEFENDANT , EICHELBERGER G FP~ANKLIN
UNCLE TO SERVE PRIOR TO EXPIRATION.
Sheriff's Costs: So ans~.~. //
Docketing 6.00 .... -. ' -
.00
Affidavit .00 R. Thomas Kline
Surcharge 10.00 Sheriff of Cu~lberland County
.00
21.00 WOLFSON & ASSOCIATES
07/06/2001
Sworn and subscribed to before me
this /3~ day of ~
..~ ~/ A.D.
Prot~ndnot ary i
T
IN THE COURT OF COMHON PLEAS OF
CUMBER ND COUNTY, PENNSYLV^N A
HCR MANOR CARE, : NO. (..)J,-- ,,.~,5'"
Plaintiff, :
:
vs. : CIVIL ACTION - LAW
:
VIOLET H. TROUT, Individually, and
G. FRANKLIN EICHELBERGER, Individually, :
and for VIOLET M. TROUT, :
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 attorney, and filing In waiting with the Court your
defenses or objections to the claims set forth against you. You are warned that If you fall 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 d~t important to you.
YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT
HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE
SET FORTH 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, slguientes, used tiene vlente (20) dias de plazo al parrJr de la fecha de lademanda y la
notifiation. Used debe presentar una apariencia escrita o en persona o pot abogado y archlvar en la
cone en forma escdta sus defensas o sus objeciones a last demandas en contra de su persona. Sea
avlsado que si used no se defienda, la cone tomara medidas y psedldo entrar una orden contra used sin
previo aviso o notificacion y pot cualquier queja o allvlo que es pedido en la peticion de demanda.
Used puede perder dinero o sus propiedades o otros derechos Importantes para used.
LLEVE ESTA DEklANDA A UN ABODOAGO 1)"ll,4EDIATAklENTE. SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFFICIENTE DE PAGAR TAL SERVICIO
VAYA EN PERSONA O LLAI~IE POR TELEFONO A LA OFICINA CUYA DIRECCION
SE ENCUENTRA ESCRITA ABA]O PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR
ASSITANCIA LEGAL.
Lawyer Referral Se~ce
Cumberland County Bar AssoclarJon
2 Liberty Avenue TRUE COPY FROM RECORD
Carllde, Pennsylvania 17013 le.Tslairc~y ~he¢-.~,l. J i~',~ ur, Ju sit tm/haml
(717) 249-3166 ~ t~M 3e~d O~ .~.,q~ ~r! ~ C. afJL.~le, I~.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, : NO.
Plainl~ff, :
..
vs. : CIVIL ACTION - LAW
:
VIOLET M. TROUT, Individually, and :
G. FRANKLIN EICHELBERGER, Individually, :
and for VIOLET M. TROUT, :
Defendant. :
COMPLAINT
AND NOW, this ~.['/ day of ~l/~f.~( ,2001, comes the Plaintiff,
l
HCR Manor Care, by and through its attorney, D~aniel F. Wolfson, Esquire, and the law
firm of Wolfson ~ Associates, P.C., and flies 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 17013.
2. Defendant Violet M. Trout, (hereinafter referred t oas "Defendant
Violet"), is an adult individual with a last known address of 940 Walnut Bottom Road,
Carlisle, Cumberland County, Pennsylvania 17013.
3. Defendant, G. Franklin Eichelberger, (hereinafter referred to as
"Defendant Frank"), is an adult individual with a last known address of 32 South
Hanover Street, Carlisle, Cumberland County, Pennsylvania 17013.
4. That Defendant Frank represented himself to be Power of Attorney for
Defendant Violet. Defendant is the nephew of Violet Iq. Trout. A true and correct
copy of the General Power of Attorney whereby Violet lq. Trout designated G.
Franklin Eichelberger as her lawful Power of Attorney is attached hereto, incorporated
herein, and collectively marked as Exhibit "A".
5. That on or about May 28, 1999, through the present, Defendant Violet
was a health care resident of Plaintiff, where she did receive and where she continues
to 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 "B".
6. That on or about lqay 28, 1999, Defendant Frank, as Defendant
Violet's Power of Attorney and Responsible Party, executed an Admission Agreement
which Agreement oudined 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 "C".
7. That Paragraph four (4) of the Admission Agreement did describe the
various responsibilities of Defendant, which responsibilities did Include payment for the
daily rate and charges for supplemental services, supplies not paid by any third party,
as well as applicable co-insurance and deductibles and all expenses of discharge or
transfer. See Exhibit "C".
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 "B" and incorporated
herein by reference.
9. That Defendants did not object to the above mentioned Statement of
Account submitted by Plaintiff to Defendants.
! 0. As of April 23, 2001, the balance due, owing and unpaid on Defendant
Violet's account as a result of said charges is the sum of One Hundred One Thousand
Five Hundred Sixty-Five and 77/100 Dollars ($101,565.77). See Exhibit "A".
II. Despite Plaintiff's reasonable and repeated demands for payment,
Defendants have failed, refused, and continues to refuse to pay all sums due and owing
on the outstanding account balance, which accrued due to residential health care
services provided to Defendant Violet, all to the damage and detriment of the Plaintiff.
! 2. Plaintiff has made numerous requests to Defendant Frank, as Power of
Attorney and Responsible Party for Defendant Violet, demanding that the sums due
and owing to Plaintiff be paid, and Defendant Frank, as Power of Attorney for
Defendant Violet, has ignored his fiduciary obligation to pay necessary and appropriate
bills and obligations for Defendant Violet.
4
! 3. That Defendant Frank has also been uncooperative in providing the
necessary information to Plaintiff to assist Plaintiff in completing an application for
Medical Assistance on behalf of Defendant Violet.
! 4. Pursuant to Paragraph eight (8) of the Fee Schedule which was attached
to the Admission Agreement, Plaintiff is entitled to receive and Defendants have agreed
to pay interest at a rate of eighteen percent (! 8%) per year on past due balances. See
Exhibit ~'C~'.
! 5. Plaintiff has retained the services of the law firm of Wolfson ~
Associates, P.C., in the collection of the amounts due from Defendants.
16. 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.
! 7. That the amount of attorney's fees which represents thirty percent
(30%) of the principal amount due and owing is the sum of Thirty Thousand Four
Hundred Sixty-Nine and 73/100 Dollars ($30,469.73).
! 8. Any and all conditions precedent to the bringing of this action have been
performed by Plaintiff.
5
19. The amount in controversy exceeds the lurisdictional amount requiring
compulsory arbitration.
WHEREFORE, Plaintiff, HCR Manor Care, respectfully requests this
Honorable Court enter judgment In favor of Plaintiff and against Defendants, Violet
M. Trout, Individually and G. Franklin Eichelberger, Individually and for Violet M.
Trout, in the amount of One Hundred One Thousand Five Hundred Sixty-Five and
77/! 00 Dollars ($ I 01,565.77), reasonable attorney fees in the amount of Thirty
Thousand Four Hundred Sixty-Nine and 73/100 Dollars ($30,469.73), 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 ! 74.03
(717) 846-1252
I.D. No. 20617
Attorney for Plaintiff
6
EXHIBIT ~A'
GENERAL POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS, that I, VIOLET M. TROUT, of 304 Center
Street, Frederick, Maryland 21701, do hereby constitute and appoint G.
FRANKLIN EICHELBERGER, of 924 Alexander Spring Road, Carlisle, Pennsylvania
17012, my true and lawful general Attorney-In-Fact for me, and generally in
my name, place and stead=
1. To enter upon and take possession of any land, buildings, tenements
or other structures, or any part or parts thereof, that may belong to me, or
to the possession whereof I may be entitled.
2. To ask, collect and receive any rents, profits, issues or income of
any and all such lands, buildings, tenements or other structures, or of any
part or parts thereof.
3. To make, execute and deliver any deeds, mortgages or leases, whether
with or without covenants and warranties, in respect of any such lands,
buildings, tenements or other structures, or of any part or par~s thereof,
and to sell and manage any such lands and to manage, repair, alter, rebuild
or reconstruct any buildings, houses or other structures, or any paL-t or
parts thereof, that may now or hereafter be erected upon any such lands.
4. To demand, sue for, collect, recover and receive any goods, claims,
debts, monies, interest and demands~whatsoever now due or that may hereafter
be due or belong to me (including the right to institute any action, suit or
legal proceeding for the recovery of any land, buildings, tenements, or other
structures, or any part or parts thereof, to the possession whereof I may be
entitled), and to make, execute and deliver receipts, releases or other
discharges therefor, under Seal, or other~ise.
~. To make, execute, endorse, accept and deliver any and all bills of
exchange, checks, drafts, notes and trade acceptances~ to execute any and all
income tax returns, Social Security applications and applications for pension
and retirement benefits and disability benefits of every nature, end any and
all other instruments, papers and documents as my Attorney-In-Feot'shell deem
necessary or appropriate~ and to enter any safe deposit box in any bank and
to withdraw therefrom any and all property therein contained belonging to me.
6. To pay all sums of money, at any time, or times, that may hereafter
be owing by me upon ~ny bill, account, or any bill of exchange, check, draft,
note.or trade acceptance, made, executed, endorsed, accepted and delivered by
me, or for me, in my name, by. my said Attorney-In-Fact.
7. To defend, settle, adjust, compound, submit to arbitration and
compromise all actions, suits, accounts, reckonings, claims and demands,
whatsoever, that now are, or hereafter shall be, pending between me a~d any
person, firm or corporation, in such manner .and in all respects aa my
Attorney-In-Fact shall think fit.
8. To hire accountants, attorneys-at-law, clerks, workmen and others
and to remove them, and appoint others in their place and to pay and allow to
the persons to be so employed such salaries, wages, or other remunerationa,
as my Attorney-In-Fact shall thin~ fit.
9. To enter into, make, sign, execute and deliver, acknowledge and
perform any contract, agreement, writing, or thing that may, in the opinion
of my Attorney-In-Fact be necessary or proper, to be entered into, made or
signed, sealed, executed, delivered, acknowledged or performed~ and
especially should I suffer any illness or accidentf physical or mental,
requiring hospitalization or the use of a convalescent home should my present
3
residential provisions be inadequate, then I do hereby empower my Attorney-
In-Fact to make all arrangements necessary and proper, in hie sole Judgment,
to place me in a hospital or convalescent home, executing the necessary
agreements or contracts therefor, and to pay all bills and expenses which'
might be incurred, all to the exclusion of any authority over my person or
property by any other person or relative.
10. To buy, receive, lease, accept or otherwise acquire, and to sell,
transfer, pledge, mortgage, hypothecate or 9therwise encumber or dispose of,
any property whatsoever and wheresoever situate, be it real, personal~ mixed
and/or intangible, upon such terms as my Attorney-In-Fact shall think proper~
and, in general, to borrow on my behalf, any and all sums of money that my
Attorney-In-Fact shall determine necessary or appropriate in connection with
the management of my affairs.
11. To sell, contract to sell, deed, convey or otherwise dispose of any
and all real estate that I may own, wherever situate~ including especially
that real estate that I own located in the City of Frederick, Frederick
County, Maryland, and being known as 304 Center Street, Frederick, Maryland
21701, and in connection with these powers, specifically, I do hereby grant
unto my Attorney-In-Fact the right and power to sign, seal~ execute,
acknowledge and deliver any and a}l instruments in writing of any kind and
nature, as may be necessary or convenient~ containing such terms and
conditions as my Attorney-In-Fact may deem advisable, to completely and
effectually complete final settlement under any contract of sale which my
Attorney-In-Fact shall deem appropriate for the sale of any and all of my
real estate, and my Attorney-In-Fact in connection with any such sale shall
have the right to receive full proceeds coming to me as a result of said
4
sale, without the necessity of the purchaser or settlement officer to see to
the disposition of the settlement proceeds or the proceeds of any such sale.
12. Under the terms hereof, I do specifically grant unto my. Attorney-
In-Fact the power to borrow on my behalf any and all sums of money that my
Attorney-In-Fact shall deem necessary and/or appropriate~ and in connection
therewith, I do hereby specifically grant unto my Attorney-In-Factthe power
to collateralize any such loan with any and all of my property of whatever
n~ture and description and wherever situate.. Additionally, I do specifically
grant unto my Attorney-In-Fact the power to purchase in any amount that my
Attorney-In-Fact shall deem appropriate, United States Treasury bonds, bills,
notes or other obligations, redeemable at par, in payment of any and all
Federal Estate taxes that might arise upon my death, with such United States
Treasury obligations being more popularly known as "Flower Bonds".
13. Intendin~ to grant unto my Attorney-In-Fact full power of
substitution, I do hereby grant unto my Attorney-In-Fact the power to
constitute and appoint, in his place and stead, as his s~bstituts, one
attorney, or more, for him, with full power of revocation vested in my
Attorney-In-Fact.
14. Without, in anywise, limiting the aforegoing, I do grant unto my
Attorney-In-Fact the power general&y to do, execute and perform any other
act, deed, matter or thing, whatsoever, as fully end effectually as I could
do, if personally present~ and it is my intention and purpose in executing
this Power of Attorney to grant unto my Attorney-In-Fact the complete power
and authority to bind me in any manner or form by any written and/or oral act
or deed as fully and completely as I myself could do if I were personally
present and acting.
§
15. This General Power of Attorney shall not be affected by my
disability, and I request that no guardianship proceeding for my property ha
commenced in the event of my disability~ but in the event any court appoints
a guardian for my person and property, I direct that my Attorney-In-Fact, G.
Franklin Eiohelberger, or his appointed substitute or substitutes, shall
serve as guardian, without bond.
16. This General Power of Attorney shall not be construed by any court
of law or by any other entity or person as a grant unto my Attorney-In-Fact
of a general power 9f appointment, and in the use of this Gener&l Power of
Attorney my Attorney-In-Pact is prohibited from dealing with any of my
progerty for less than valuable consideration.
And I, the said Violet M. Trout, do hereby ratify and confirm all
whatsoever my said Attorney-In-Fact, or his substitute or substitutes, shall
do, or cause to be dgne, in, or about the premises, by virtue of this General
Power of Attorney.
IN WITNESS WHEREOF, I have hereunto set my hand and seal, in the County
of Frederick, State of Maryland, on this~ ~ day of ~_~, 1992.
WITNESS:
~Violet M. Trout
EXHIBIT "B"
MANORCARE CARLISLE 372
940 NALNUT BOTTOM ROAD
CARLISLE, PA 170£3
(717)-249-0085
PRIVATE
FRANK EICHELBERGER
jFOR VIOLET TROUT ROOH 165 -A
32 S. HANOVER ST. APT. 2
CARLISLE, PA 17013 Ple3$e Return Th~s Po~io~
~T,,VIO'LET 98139 06/29/99 01131101
L-_ SERVICE CODE SERVICE RENDERED I CHARGES i CREDITS
0[/01/01 BALANCE FORWARD 86,866.13 I
01/12/01 30009 PHARMACY NONLEGEND ( QTY i ) 13.83
01/21/01 51501 WOUND TREATMENT ( OTY 11 ) 88.00
01/31/01 51801 TOTAL INCONT-DLY FEE ( QTY 31 ) 93.00
01/31/01 53101 NUBASIC ~UICE BERRY 163 ( QTY 124 ) 163.68
01/31/01 5~201 NTRTNL/ENTRL SERV GRP 3 ( (~"Y 93 ) 372.00
01/09/~1 29009 pH~RMACY~LEG?~O ( QTY. ~ ) 101.62
02/OlL~/28~e/1' ~0~ Rod'M~'C~AR§E"~/~B-' "'D'AY~"AT ' 1-38~00" "~ 3.864.00
PAYMENT OUE BY THE
10TH OF THE MONTH
91,562.2~
AMOUNT DUE
./
MANORCARE CARLISLE 372
948 NALNUT BOTTOM ROAD
CARLISLE, PA 17013
(717)-249-0085
) PRIVATE
FRANK EICHEmLBERGER
FOR VIOLET TROUT ROOM 165 -A
32 S. HANOVER ST. APT. 2
Please Relurn This PoRion
CARLISLE, PA 17~13 WllhYour~aymen/
TROUT, VIOLET 98139 e6/29/99 02/28/0[
DATE OF
02[~1/~i BALANCE FORWARD 91,562.26
e2/el/01 11100 BEAUTY W & S 1/16 ( QTY I ) 9.00
02/e[/el 1110e BEAUTY PERM 1/23 ( QTY 1 ) 36.0e
e2/e1/o1 11100 BEAUTY W & S 1/30 ( QTY i ) 9.00
02/el/01 1110e BEAUTY 'bi & S 1/e2 ( QTY 1 ) 9.00
e2/el/01 111e0 BEAUTY W & S 1/09 ( QTY i ) 9.00
02/06/el 29001 PHARMACY LEGEND ( QTY 1 ) 107.91
e2/05/e1 51501 WOUND TREATMENT ( QTY 8 ) 64.00
02[28/01 51891 TOTAL ZNCONT-DLY FEE ( QTY 28 ) 84.00
e2/28/01 531el NUBASIC 3UICE BERRY 163 ( OTY 112 ) 147.84
0~/28/01 53201 NTRTNL/ENTRL SERV GRP 3 ( QTY 84 ) $$6.~
e2/23/01 3ee01 PHARMACY NON LEGEt4D ( QTY 1 ) 10.87
e2/05/01 1110~ BEAUTY AND BARBER ( QTY 1 ) 9.0e
02/13/01 11100 BEAUTY AND BARBER ( QTY I ) 9.00
$U8 TOTALS 92,402.B8 .~
CARRIED Fi..
AMOUNT DUE
MANORCARE CARLZSLE 372
940 WALNUT BOTTOM ROAD
CARLZSLE, PA 17013
(717)-249-0085
FRANK E:CHELBERGER PRIVATE
FOR VIOLET TROUT ROOM 165
32 S. HANOVER ST, APT. 2
CARLISLE, PA 17013 PleaseRetumT~*$Po~ion
WithYour~ayment
TROUT, VIOLET 98139 06/29/99 03/31/01
. OATE OF
03/01/01 BALANCE FORNARO 96,811.38
63/05/01 51501 WOUND TREATMEr~T ( QTY 5 ) 40.00
03/31/01 51801 TOTAL INCONT-DLY FEE ( QTY 31 ) 93.00
03/31/01 53101 NUBASIC ~UZCE BERRY 163 ( QTY 124 ) 163.68
03/31/01 53201 NTRTNL/ENTRL SERV GRP 3 ( ~TY 93 ) 372.00
03/23/01 30001 PHARMACY NON LEGEND' ( ~TY I ) 13.71
03/07/01 11100 BEAUTY AND BARBER ( QTY i ) 9.90
03/13/01 11100 BEAUTY AND BARBER ( OTY I ) 9.00
03/20/01 11100 BEAUTY AND BARBER ( QTY I ) 9.00
e3/27/01 11100 BEAUTY AND BARBER ( QTY 1 ) 9.00
03/01/01 REV LAST NO RC 4,123.¢
03/01-03/31/01 ROOM CHARGE 31 DAYS AT 138.00 4,278.00
04/01-04/30/01 ADV ROOM CHARGE 30 DAYS AT 138.00 4,140.00
02/28/01 AD3 CORRECT R&B FOR 2/01 4,123o¢
$U8 TOTALS 105,947.77 8,246.(
CARRZED Ft.
AMOUNTDUE
HCR.ManorCare -
MANORCARE CARLISLE 372
940 WALNUT BOTTOM ROAD
CARLISLE, PA 17013 PAGE 2
(717)-249-0085
FR Ai'lK EICHELBERGER PRIVATE
FOR V'rOLET TROUT ROOM 165 -A
32 S. HANOVER ST. APT. 2
CARLISLE. PA 17013 Please Return This Portion
With Your Payment
TROUT, VIOLET 98139 06/29/99 03/31/01
SERVICE I I CHARGES I CREDITS
FWD FROM PRECEDING STMT 105,947.77 8,246,e(
02/28]01 AD3 CORRECT R&B FOR 2/01 3,864.00
PAYHENT DUE
UPON RECEIPT
101,565.7;*
AMOUNT DUE
EXHIBIT "C"
(C '- ' ADMISSION AGREEMENT Man C re
ONTRACT BETWEEN PATIENT/RESIDENT AND FACILITY Health Services
~'I'HIS ADMISSION AGREEMENT (the Agreement ) is entered into th~s .... day of
~t'O[~ ~0~ (the "Patient/Resident"), and/or
(the "Responsible Party")· ~ used heroin, the term "Patient/Resident" shall also mean the Responsible
Party, if any. The pa~ies agree as follows:
1. Commencement· This Agreement shall begin on the date of admission of the Patient/Resident
to the Facility.
2. Termination of Agreement, Discharge and Transfer.
a. Termination by Patient/Resident. The Patient/Resident may terminate this Agreement by
giving the Facility at least five (5) days advance written notice· The Patient/Resident is responsible
for payment of all charges for five (5) days after notice is given, or until the Patient/Resident actually
· leaves the Facility, whichever is last. If the Patient/Resident leaves the Facility (i) before the attending
physician discharges the Patient/Resident, or (ii) against medical advice, the Patient/Resident and
Responsible Party agre,e to assume all responsibility for injury or harm to the Patient/Resid6nt, and
hereby release the Facility, its employees and agents, from all liability connected with such departure.
b. Termination by Facility. The Facility may terminate this Agreement and discharge the Pat-
ient/Resident upon at least thirty (30) days prior written notice if (1) the Patient/Resident's needs
cannot be met; (2) the Patient/Resident presents a danger to the health or safety of other indivi-
duals; (3) the Patient/Resident fails to pay charges for supplies or services after notice; (4) the
Patient/Resident's health has improved sufficiently so that the Patient/Resident no longer needs the
services provided; or (,5) the Facility ceases to operate. However, the Patient/Resident may be
transferred or discharged upon less than thirty (30) days notice if: (1) an immediate transfer or
discharge is required due to the Patient/Resident's medical needs; (2) the Patient/Resident presents
a threat to the health and safety of individuals in the Facility; or (3) the Patient/Resident has not
resided in the Facility for thirty (30) days. Such notice shall be given as soon as practical. The
Patient/Resident acknowledges receipt from the Facility of materials as to the Patient/Resident's right
to appeal a discharge decision with State authorities and the appeals process. If this Agreement is
terminated and/or the Patient/Resident is discharged by the Facility, the Responsible Party agrees
to accept custody of the Patient/Resident upon discharge and cooperate with the Facility to facilitate
the Patient/Resident's discharge.
3. Responsible Party· The Patient/Resider~t shall execute Exhibit A regarding Responsible Party
appointment.
4. Fees & Payments. The Patient/Resident is responsible for, and shall pay, the daily rate and
charges for supplemental services and supplies not paid by any third party as described in the Fee
Schedule, attached as Exhibit B, as well as applicable co-insurance and deductible amounts and all
expenses of discharge or transfer·
5. Release of Information· The Patient/Resident hereby authorizes all persons and/or entities to
release all or any part of his/her medical/health records to the Facility. The Patient/Resident also
authorizes the release of records or information to any health care institution to which the Patient/
Resident may be transferred, any provider involved in the care of the Patient/Resident, any third
party payor, including, but not limited to, government and private insurers, or any other person entitled
or authorized to receive such information by law or by the Patient/Resident.
MHC-0Oa-=O (Rev. 7/961 P~ 3 I of 3
Conditions (,collectively referred to as "Conditions")
1. The assets of the Patient/Resident will be utilized to pay, when due, all costs incurred by
the Patient/Resident at the Facility not covered by a third party payor, at the rates set forth
in the Fee Schedule (Exhibit B). The Responsible Party will arrange for the provision of
personal clothing and care supplies as needed or desired by the Patient/Resident and as
required by the Facility.
2. The assets of the Patient/Resident will be utilized to replace any and all furnishings or other
property of the facility, other Patient/Residents or employees of the facility damaged by the
Patient/Resident.
3. All of th.e information, including but not limited to that contained on th.e attached Application
for Residency, dated .'?~.~_ -F,'c'C . : 199 ~ , and which ~s attached hereto an.d
made part of this Exhibit af~ of the Admlaslon Agreement, is true and accurate as of th~s
date and all assets listed in the application are in fact available to the Patient/Resident for
the Patient/Resident's care while at the facility.
4. Neither the Responsible Party nor the Patient/Resident will take action to dissipate or other-
wise transfer the' Patient/Resident's assets and/or assets which are available for the Pat-
ient/ Resident's care so as to prevent such assets from being used to pay for the care of
the Patient/Resident while at the facility.
5. When the assets available to pay for the Patient/Resident's care at the Facility are not
sufficient to pay for the anticipated length of stay, the Responsible Party or Patient/Resident
will so notify the Facility and will file, on behalf of the Patient/Resident, all applications and
other documents necessary or advisable to qualify him/her for all third party payor programs
for which he/she may be eligible, including Medicaid.
6. If the Patient/Resident is a Medicaid Patient/Resident, that Responsible Party or Patient/
Resident will provide financial information regarding monthly credits, increases and decreases
in the Patient/Resident's bank account(s) and other assets to the Facility to enable the
Facility to provide requested data to Medicaid representatives.
7. If the Patient/Resident is covered by a third party payor, the assets of the Patient/Resident
will be utilized to pay extra charges n,ot covered by the third party payor in a timely manner,
and to notify the administrator of the Facility of any problem anticipated in paying such charges.
The undersigned understands and acknowledges that the Facility is relying upon the above Conditions
in admitting the Patient/Resident to the Facility and understands and acknowledges that if the above
warranties ..a. nd repres..e, ntati.o..ns are .n~! true, or if the abov/~ ~ovenants and agreements .are not
complied w,th, the Fac~hty will have detrimentally relied upon~ft~n and ~e Facility will suffer financial
harm and loss. ~ ,~
Responsible p_~r{~-~ Signature
Reepo~lb.~.~"arty - Prl~lt~d N~-~-
imo-~o~-~o (Rev. 4/961 pg 7 ~ of 2
· Federal Resider'.t Rights · Barber/Beauty Services
· Resident Responsibilities · Mail Policy
· Life Sustaining Treatment Policy · Voting Materials
· Medical/Nursing Education · Photo/Media Events
· Dental, Vision and Hearing Services · Personal Fund Account Procedure
· Interdisciplinary Care Conference · Tobacco Policy
· Utilization Review Meetings (if applicable) · Grievance Procedures
· Personal Laundry Policy · State Resident Rights (if applicable)
14. GOVERNING LAW. THIS AGREEMENT SHALL BE GOVERNED AND CONSTRUED IN
ACCORDANCE WITH THE LAWS AND REGULATIONS OF THE STATE WHERE THE FACILITY IS
LOCATED. TO THE EXTENT ANY PROVISION HEREOF CONFLICTS WITH STATE LAW, STATE LAW
SHALL CONTROL. THE STATE LAW ADDENDUM ATTACHED HERETO AS EXHIBIT D SETS FORTH
ANY DELETIONS FROM OR ADDITIONS TO, THIS AGREEMENT REQUIRED BY STATE LAW, WHICH
AMENDMENTS SHALL BE A PART OF THIS AGREEMENT.
15. Miscellaneous. The provisions of this Agreement shall bind the parties, their respective executors,
administrators, heirs, beneficiaries, and assigns. The waiver by either party of any breach or 'default
of this Agreement shall ~ot operate as a waiver of any subsequent breach or default. The provisions
of this Agreement shall be severable and the invalidity or unenforceability of any provision shall not
affect the validity or enforceability of any other provision. This Agreement and all Exhibits are the
entire agreement and any changes shall be in writing and signed by both parties,
IN WITNESS WHEREOF, the parties hereto have executed this Admission Agreement as of the day
and year above written. ~
Facility Representative - STgnatum
Facility Representativ~ -,ASrln-t~d Name & Title Respon ':.qjj:x~'Party.,,-/Printed Name
THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
HCR MANOR CARE, : NO. 01-3295
Plaintiff :
VS.
:
VIOLET M. TROUT, Individually, and : CIVIL ACTION - LAW
G. FRANKLIN EICHELBERGER, Individually, :
and for VIOLET 1,4. TROUT, :
Defendants. :
PRAECIPE TO DISMISS COMPLAINT
Please dismiss the above flied Complaint without prejudice in the above captioned
matter.
Respectfully submitted,
WOLFSON ~ ASSOCIATES, P.C.
Daniel F. Wolfson, Esquire~
267 East Market Street
York, Pennsylvania 17403
717/846-1252
Dated: ~~/ I.D. #20617
Attorney for Plaintiff