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HomeMy WebLinkAbout11-7115T JULIA MANOR LLC t/a JULIA IN THE COURT OF COMMON PLEASF MANOR HEALTHCARE CENTER : CUMBERLAND COUNTY, PENN! N SA Plaintiff : = - - _,fi -- _ v. NO. 2011- CIVIL TERM JOSEPH R. BOCK and ,, =--I TAMMY L. BOCK 4" , AGENT FOR JOSEPH R. BOCK CIVIL ACTION-LAW and INDIVIDUALLY -- r , 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 are served, by entering a written appearance personally or by an attorney and filing in writing with the court, your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 -05 k0e).00'a01AJ0" ?#?y686 I JULIA MANOR LLC t/a JULIA MANOR HEALTHCARE CENTER : Plaintiff V. JOSEPH R. BOCK and TAMMY L. BOCK, AGENT FOR JOSEPH R. BOCK and INDIVIDUALLY, ; Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2011- ? 1 + S CIVIL TERM CIVIL ACTION-LAW COMPLAINT NOW, comes Julia Manor LLC t/a Julia Manor Healthcare Center ("Julia Manor"), by and through its attorneys, BARIC SCHERER LLC, and files the within Complaint and, in support thereof, sets forth the following: 1. Julia Manor is a Maryland limited partnership duly authorized to conduct business in the Commonwealth of Pennsylvania with a business address of 333 Mill Street, Hagerstown, Maryland 21740. 2. Defendant, Joseph R. Bock, is an adult individual with a last known mailing address of P.O. Box 334, Blue Ridge Summit, Franklin County, Pennsylvania 17214. 3. Defendant, Tammy L. Bock, is an adult individual with a residence address of 3 Wiltshire West, Carlisle, Cumberland County, Pennsylvania 17015. 4. Julia Manor operates a resident skilled care nursing facility located at 333 Mill Street, Hagerstown, Maryland 21740. 5. On or about October 16, 2010, Joseph R. Bock sought to be admitted to the Julia Manor facility. 6. On or about October 16, 2010, Tammy L. Bock as attorney-in-fact for Joseph R. Bock, executed a Financial Agreement on behalf of Joseph R. Bock at the facility. A true and correct copy of the Financial Agreement is attached hereto as Exhibit "A" and is incorporated. 18. The Financial Agreement provides for the recovery of a penalty for late payments in the amount of 1.5% per month. 19. The Financial Agreement provides for the recovery of reasonable attorney fees and costs incurred by Julia Manor to collect a debt due and owing to Julia Manor. WHEREFORE, Plaintiff requests judgment in its favor and against Joseph R. Bock and Tammy L. Bock for the sum of $37,045.00 plus additional interest, costs and expenses and any additional amount coming due to the date of award and attorney fees and costs. COUNT II-MONEY HAD AND RECEIVED JULIA MANOR v. TAMMY L. BOCK 20. Plaintiff incorporates by reference paragraphs one through nineteen as though set forth at length. 21. During the period of residence at the facility, Tammy L. Bock has been receiving social security and pension benefits of Joseph R. Bock. 22. The proper use of those funds would have been to pay the costs of care accruing for the care of Joseph R. Bock at Julia Manor. 23. At the time of receipt of those funds, Tammy L. Bock knew that these funds should be paid over to Julia Manor for the costs of Joseph R. Bock's care. 24. Tammy L. Bock gave no consideration for the funds of Joseph R. Bock she has received. 25. Demand has been made upon Tammy L. Bock to tender the funds of Joseph R. Bock to Julia Manor and she has failed and refused to do so. WHEREFORE, Plaintiff requests judgment in its favor and against Tammy L. Bock requiring her to: a) return the subject matter in specie; b) pay over the value if Tammy L. Bock has consumed the money in beneficial use; C) pay its value if Tammy L. Bock has disposed of the funds received; and d) award costs, expenses and interest. Respectfully submitted, C SC R LLC David A. Baric, Esquire I.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Attorney for Plaintiff dab.dir/juliamanor/bock/complaint.pld VERIFICATION The statements in the foregoing Complaint are based upon information which has been assembled by my attorney in this litigation. The language of the statements is not my own. I have read the statements; and to the extent that they are based upon information which I have given to my counsel, they are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. 4904 relating to unswom falsifications to authorities. DATE: -) J jai Allison Klimowicz Corporate Operations Center Director Magnolia Management, Inc./Julia Manor Resident's Agent Financial Agreement with Julia Manor This Contract Has Been Approved by The Maryland Department of Health and Mental Hygiene 1. This Contract is between Julia Manor (the "Facility", or "we", or "us") and _ 714141,4 A67 " /-f, (the "Agent" or "you") because you have access t (use, many m ent, or control of) the income, funds and/or assets of v (the "Resident") and because you are will' g to act on behalf of the Resident. A checklist of the obligations and rights you have as the Resident's Agent is at Exhibit 1. The questions on the checklist must be answered by you and the checklist is incorporated into this Agreement. 2,. In consideration of your payment and promises made in this Agreement, the Facility agrees to do the following; Health Care Services A. We will provide the Resident with general nursing care and nursing treatments such as administration of medication, preventive skin care, assistance with bathing, toileting, feeding, dressing and mobility. (Throughout this Agreement is information about which services are covered in the Facility's daily rate and which are available for an additional charge.) B. When the Resident's doctor orders health care services which we do not have the capability to provide (with the Resident's or your approval), we will arrange for the services to be provided by an outside provider, or we will arrange for the Resident's transfer to the hospital or other health care providers. 4 Financial Agreement, Page 1 EXHIBIT "A" Personal Services C. We will provide the Resident with room and board, housekeeping services, recreational and social programs, and personal care. D. We will provide the Resident with a reasonable amount of storage space for the Resident's personal belongings. E. At the Resident's or your request, we will maintain the Resident's personal funds and will comply with the laws and regulations relating to our management of the Resident's funds. See Exhibit 5. 3. Paying for the Resident's Care. A. Who Can be Required to Pay for the Resident's Care Only the Resident and the Resident's insurers can be required to pay for the Resident's care. You cannot be required to pay for the Resident's care from your own funds, unless you knowingly and voluntarily agree to pay for the cost of the Resident's care with your own funds.' By signing this Agreement, you and the Resident agree to pay for care and services provided to the Resident with the Resident's income, funds and assets. (By signing this Agreement, you intend to bind the Resident to all obligations of this Agreement, including payment for care and services.) If you fail to pay a Facility bill, we may request a court to order such payment. You understand you may not use the assets or income of the Resident for any purpose ' Whenever the phrase "you will be charged", "you pay", or "you agree to pay" are used in this Agreement, it shall be subject to the qualifications of this paragraph. Financial Agreement, Page 2 / that is not authorized by the Resident, or that is not necessary for the direct and immediate welfare of the Resident.2 You agree to provide us with all information about the Resident's finances and health. You understand that, if we later find that you knowingly provided the Facility with incomplete or inaccurate information, we will consider that a breach of this Agreement. It is anticipated that the Resident's care will be paid for by (circle one or more): The Medicare Program; ® The Medicaid Program (also known as "Medical Assistance"); Other insurer, please specify 662 8 You with the Resident's income, funds and/or assets; as You with your own income, funds and/or assets; 6?1 Other, please specify: _ ,- o h,J 4ia&J,-o C 2 If there is an abuse of the Resident's funds, the person who misused the funds is guilty of a misdemeanor and, on conviction, is subject to a fine up to $10,000. "Abuse of funds" means using the assets or income of a resident against the express wishes of the resident unless the expenditure was necessary for the direct and immediate welfare of the resident. Abuse also means using the assets or income of the resident for the use or benefit of another unless such use is for the direct and immediate benefit of the resident or is consistent with an express wish and past behavior of the resident. Financial Agreement, Page 3 It is understood that Medicare and Medicaid will make the determination concerning the Resident's medical and financial eligibility for payment by those programs, You agree to pay either directly or through a third party payor for all items and services provided to the Resident by the Facility. You request that the Facility send the bills to: S. Private Pay Residents. The items and services included in our daily rate of $225-$275 which include basic room, board and general nursing care as required by the Resident's medical condition are listed in Exhibit 2. Payment for items and services that are included in the daily rate is payable one month in advance and due on the first of each month. You agree to make timely payments. You understand and agree that the Resident will be charged separately for additional items and services which the Resident or you (or the Resident's physician, with the Resident's or your approval) request and which are not included in our daily rates such as special nursing care, special equipment, pharmacy charges, laboratory charges and additional services such as telephone expenses, clothing, beauty and barber services and newspapers. A list of many of the ordinary items and services for which the Resident may be charged is at Exhibit 2. If the Resident, or you, or the Resident's physician (with the Resident's or your approval) request items or services other than those listed in Exhibit 2, you will be notified of the cost. Payment for these additional items and services is due within thirty (30) days after the Resident or you (or the Resident's physician with the Resident's or your approval) have requested them, and the Resident has received and been billed for them. Within ninety (90) days of receiving an item or service, or within thirty (30) days of Financial Agreement, Page 4 46 payment, you or the Resident have the right to ask us for an itemized statement that briefly but clearly describes each item and service, the amount charged for it, and the identity of the payer billed for the service. You understand and agree that you are responsible for paying the Facility for items and services provided to the Resident during any period of time in which the Resident is or was a resident of the Facility and during which the Resident has not been determined eligible for Medical Assistance. If you do not pay the amount owed us after receiving Facility bills and we hire a collection agency or attorney because of your breach of this Agreement, you agree to pay their fees, expenses and court costs with your own funds. If you do not pay what is owed the Facility, you agree to apply to Medical Assistance for a determination of the Resident's income and assets available to pay the cost of the Resident's care. Once Medical Assistance determines the income and assets available to pay for the Resident's care, you agree to use such income and asset to pay the Facility's bills,3 The Facility may require you to distribute any funds, including income or assets of the Resident, which the Medical Assistance Program has determined to be available to pay for the cost of the resident's care, to the Facility, promptly when due. (Your request for this determination is not the same as applying for Medical Assistance on behalf of the Resident.) You agree to notify the Facility promptly if the Resident has insufficient income, funds, or assets to meet the s If you do not request a determination by Medical Assistance, or if payment is not made with the income and assets determined to be available for the Resident's care, the Facility may ask the court to order you to obtain the determination or to make payment, If you are willfully or grossly negligent in not paying the amount determined by Medical Assistance to be available for the Resident's care, you may have to pay a civil money penalty of at least that amount with your own money. Financial Agreement, Page 5 Resident's financial obligations to the Facility and you agree to apply for Medical Assistance benefits in a timely manner and to cooperate fully in the Medical Assistance eligibility determination process. If you do not apply or cooperate fully in the process, the Facility may ask the court to order you to do so. If you are no longer able to pay for the Resident's care at the Facility and the Resident is not eligible for Medical Assistance, you and the Resident will be notified of the Facility's intention to discharge the Resident for non-payment. You agree to continue to pay the Facility's prevailing daily charges until the date of the Resident's departure. If there is any dispute about whether the Resident should be discharged, the notice and other requirements in Section 4.F. apply, If transfer or discharge becomes necessary because you or someone else abused the Resident's funds, the Facility will request that the Attorney General investigate which may result in prosecution. If you believe that you may need to apply for Medical Assistance later for the Resident, you may want to find out now if the Resident is "medically eligible" for nursing home payment by Medicaid. (This is not, however, the same as applying for Medical Assistance benefits.) See Exhibit 313. [The Exhibit is written in terms of the Resident. Financial Agreement, Page 6 A C. Medicare Resident We participate in the Medicare Program. Medicare may pay for some or all of the Resident's nursing home care. For information on Medicare, see Exhibit 3A. [The Exhibit is written in terms of the Resident.] If the Resident is eligible for Medicare, you have the right to have claims for the Resident's nursing home care submitted to Medicare. You understand and agree to pay the Facility for amounts not covered by Medicare, including the co-payment which Medicare requires for most covered services, currently 137.50, which Medicare changes yearly. You also understand that some items and services offered by the Facility are not covered by Medicare and if you want (on behalf of the Resident) or the Resident wants any of these items or services, you agree to pay for them. (A list of the items and services not covered by Medicare and charges for them are at Exhibit 4.) 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, you agree to pay any required deductible, and any applicable co-insurance. D. Medicaid Residents. We participate in the Medicaid Program. For information on Medicaid, see Exhibit 3A. [The Exhibit is written in terms of the Resident.] The Resident is not required to give up any of the Resident's rights to Medicaid benefits to be admitted or to stay here. If the Resident's private funds are used up during the Resident's stay here and the Resident is eligible for Medicaid, we will accept Medicaid payments. Although it is the Resident's and your responsibility to apply for and retain Medicaid benefits for the Resident, we will assist you, by promptly providing Medical Assistance with all required information in our possession. In order to be eligible for Medicaid coverage, you must meet all of the Medicaid requirements. If the Resident is eligible for Medical Assistance, the Facility may not Financial Agreement, Page 7 A V charge, ask for, accept or receive any gift, money, donation or consideration other than Medicaid reimbursement as a condition of the Resident's admission or continued stay here. If the Resident receives Medicaid, the Resident agrees to pay a portion of his/her income checks to the Facility; the amount of which is determined by the local Department of Social Services. Or, while awaiting a Medicaid decision, the Facility will estimate the amount of the Resident's income due to the Facility. You authorize the Facility to endorse or otherwise cash such checks, disburse the personal needs portion and other allowable personal expenses to you or others designated by the Resident as entitled thereto, and to apply the balance to the Resident's cost of care. A list of the items and services covered by Medicaid (which are published at COMAR 10.09.10.04) is posted in the Facility at the following location: at the reception desk. It you or the Resident would like your own copy, the Facility will provide one. Some of the items and services that we offer are not covered by Medicaid. If you or the Resident want any items or services which are not covered by Medicaid to be provided to the Resident, you will have to pay for them. A list of the items and services not covered by Medicaid and the charges for them are at Exhibit 4. Payment for items and services that are not covered by Medicaid is due after the Resident, or the Resident's physician with your, or the Resident's approval, have requested them and the Resident has received them and you have been billed for them. Within ninety (90) days of the Resident receiving an item or service, or within thirty (30) days of payment, you or the Resident have the right to ask us for an itemized statement that briefly but clearly describes each item or service, the amount charged for it, and the identity of the payer billed for the service. You understand that non-payment of items and services not covered by Medicaid may result in a discharge action for Financial Agreement, Page 8 , non-payment of bills. If all of the Resident's personal needs have been met, you understand that money in the Resident's personal funds account may be needed to pay for items and services not covered by Medicaid which were requested by you or the Resident (or the Resident's physician with the Resident's, or your approval) and are provided by the Facility. E. Change in Status Regardless of any change in your payment status during the Resident's stay at the Facility, or any rejection or delay in obtaining eligibility under any payment program, you are responsible for all nursing home charges and fees that are not timely paid under a payment program. If the Resident is eligible to change status from Private Pay to Medicaid, the Facility will provide you and/or the Resident with information regarding an application for Medicaid eligibility, and assist with the application process. However, you and/or the Resident have the ultimate duty and obligation to take all steps necessary, in a timely manner, to file for and obtain Medicaid eligibility. If you and/or the Resident fail to take all steps necessary in a timely manner to file for and obtain Medicaid eligibility, the Resident will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had an application been made in a timely and proper manner. F. Increases in Charges and Fees, Any time we increase a fee or charge for an item or service or add a new item or service, we will provide you and the Resident with forty-five (45) days advance written notice. Financial Agreement, Page 9 G. Interest Penalties. We may not charge you a penalty if you pay the Resident's itemized statement on time. Payment is on time if it is made within 45 days of the date the bill is postmarked, or 30 days after the end of the billing period, whichever is later. The interest penalty we charge is 1.5% of the amount due, calculated on a monthly basis. For any bill delinquent over one month, penalties will be calculated on a simple basis.' H. Private Duty Nurses/Geriatric Aides. If you or the Resident want a private duty nurse or a private duty geriatric aide for the Resident, you are responsible for selecting a person licensed and/or certified according to Maryland laws and regulations. You are also responsible for paying him or her, and for letting us know that you have hired one. The person you hire is not an employee or agent of the Facility, but he or she must meet our standards and follow our policies and procedures. Employees of the Facility may not serve as private duty nurses or private duty geriatric aides. 1. Limitations of Liability. The Facility is obligated to take reasonable precautions to provide the Resident and the Resident's personal belongings with security, including providing a reasonable amount of secured space for the Resident's belongings. The Facility, however, cannot be responsible for any loss or damage to the Resident's valuables or money that is not delivered into the custody of the Facility Administrator or his/her designee, unless that loss or damage is caused by the negligent or willful action of the Facility staff. Additionally, eye glasses should be marked for identification and ' The Facility may not charge interest on a Medical Assistance contribution to cost of care for covered services. Financial Agreement, Page 10 41 dentures should be in a marked receptacle when not in use, the Facility assumes no responsibility for their loss or damage. The Facility's Policies and Procedures concerning the Resident's personal funds and the Resident's personal property are at Exhibit 5. If, in spite of the Facility's best efforts, there is loss or damage to property, or injury or death to persons, which is mutually agreed to be or determined by an appropriate third party to be caused solely by the Resident, you agree to be responsible for the damage, injury, or death to the extent of the Resident's income, funds and assets. This responsibility includes payment for damages and all costs including reasonable attorneys fees required to defend a claim resulting from such damage. In addition, although the Resident has the right to make the Resident's own health care decisions, including the right to refuse treatment, you accept responsibility to the extent of the Resident's income, funds and assets for any consequences resulting from the Resident's refusal to accept nursing or medical treatment or service considered by the Resident's physicians to be necessary for the Resident's care. 4. Resident Rights. As a Resident of this Facility, the Resident has many rights under federal and State law. Some of those rights are listed in this section. You and the Resident will be given a written description of all of the Resident's rights. A. The Resident's Right to Make Decisions. The Resident has the right to make the Resident's own medical decisions, to manage the Resident's personal affairs and to access the Resident's medical records as permitted by law. If the Resident becomes incapable of making the Resident's own decisions, it may be necessary for someone else to make decisions for the Financial Agreement, Page 11 Resident. For this reason, we recommend that the Resident make advance directives for medical decisions and appoint a Power of Attorney for financial decisions, but the Resident is not required to do so. It is recommended that the Resident consult with an attorney to prepare a financial Power of Attorney. As part of the admission process, you and the Resident will be given a description of the Resident's legal rights to decide about the Resident's future medical treatment, as well as information about making advance directives. If the Resident makes an advance directive, you should provide the Facility with a copy. B. Selection of a Doctor or Other Provider. The Resident may select the Resident's own doctor and other health care providers. The Resident's doctor and other health care providers must follow our policies.' The Resident or you on behalf of the Resident, or the Resident's insurer, including the Medicaid Program, are responsible for the doctor's payment. If the Resident does not have a doctor, the Resident or the Resident's health care representative may choose one from the list of physicians who practice here. If the Resident or the Resident's health care representative is unable to choose a doctor, we will assign one to the Resident from this list. In case the Resident's doctor is not available when needed, our Medical Director, or designee, will take care of the Resident until the Resident's doctor is available. Some services the Resident may require are available through outside providers. Some available outside providers and whether the Facility has a shared ownership interest with the Provider are at Exhibit 6. 5 If the Resident's doctor and other health care providers do not follow Facility policies and procedures, the Facility will ask the Resident to choose other providers. Financial Agreement, Page 12 A C. Personal Property and Financial Affairs. The Resident has certain rights relating to the Resident's personal property and managing the Resident's financial affairs. These rights may be exercised by you. So that you are aware of these rights the Facility's policy and procedure concerning these rights is at Exhibit 5. D. The Resident's Right to Make Complaints and Suggest. Changes in Policies and Services. You, the Resident, or any other person may make complaints about the Resident's care in the Facility and may also suggest changes in the policies and services of the Facility. The Resident will not be harassed or discriminated against for making a complaint or suggesting a change in a policy or service. You or the Resident may present the complaints orally or in writing to Facility staff or the Administrator, or to one of the following State agencies: Office of Health Care Quality Bland Bryant Building Spring Grove Hospital Center 55 Wade Avenue Catonsville, MD 21228 (410) 402-8110 (877) 402-8219 (800) 735-2258 (TTY) (410) 402-8234 (Facsimile) Department of Aging 301 West Preston Street Room 1004 Baltimore, MD 21201 (410) 767-1074 (800) 243-3425 (410) 767-1083 (TTY) (410) 333-7943 (Facsimile) If the Facility is unable to resolve the complaint, it will be sent to the Department of Aging and the Office of Health Care Quality. A hearing may be requested from that Office. I'll Financial Agreement, Page 13 F. Holding-The Resident's Bed If The Resident Leaves the Facility. If the Resident is hospitalized or on leave from the Facility, we will hold the Resident's bed as follows; 1. If the Resident is a private-pay resident, or is receiving inpatient care reimbursed under the Medicare Program (and the Resident is not covered under Medicaid), we will hold the Resident's bed for as long as you pay for it at the current daily rate unless you or the Resident notify us otherwise. 2. If Medicaid pays for all or part of the Resident's nursing home care and the Resident needs to be hospitalized, we will hold the Resident's bed for up to the maximum number of days required under Medicaid regulations, currently 15 days. If the Resident is away from the Facility on a leave of absence which is provided for in the Resident's plan of care and approved by the Resident's physician, we will hold the Resident's bed for up to the maximum number of days required under Medicaid regulations, currently 18 days each calendar year. While we are holding the Resident's bed, you are still required to pay the Facility any amount for which you are responsible as determined by the Medicaid Program. If the Resident's hospitalization or leave of absence exceeds the number of days paid by the Medicaid Program, you may pay privately to reserve the Resident's bed for the additional days. In any case, if the Resident's hospitalization or leave of absence exceeds the total number of days paid by the Medicaid Program or any other payer, the Resident has the right to be readmitted to the first available gender-appropriate semi-private bed. The maximum number of days for which the Medicaid Program will pay to hold the Resident's bed for hospitalization or leave of absence may be increased or decreased based upon changes in the law or the regulations established by the Maryland Medical Assistance Program. Financial Agreement, Page 14 /_O? 3. If the Resident has applied for Medicaid, the Resident's bed will be reserved in accordance with Paragraph 2. However, if the Resident is found to be ineligible for Medicaid, then you are required to pay for the bed at a private pay rate as described in Paragraph 1. 4. Other third-party payers may or may not have a bed hold policy. We will discuss this if it applies to the Resident. F. Transfer and Discharge. The Resident has the right to remain here, and may not be transferred or discharged against the Resident's will, except for the following reasons: (a) the Resident's condition has improved so that the Resident no longer needs the services we provide; (b) the transfer or discharge is necessary for the Resident's welfare and the Resident's needs cannot be met by the Facility; (c) the health or safety an individual in the Facility is endangered; (d) you have failed to pay, after reasonable and appropriate notice, or under Medicare or Medicaid or otherwise to have paid for, a stay at the Facility; or (e) the Facility ceases to operate. If we decide that the Resident should be transferred or discharged for one of these reasons, we will notify the Resident and you, the Resident's family member, guardian or representative, by letter 30 days in advance. We will also notify the Office of Health Care Quality and the Department of Aging. If the Resident is transferred because of an emergency situation, we will provide the required notice as soon as reasonable. The involuntary discharge letter will contain the reasons for the transfer or discharge and its effective date, and the Resident's rights regarding discharge or transfer. The letter will also tell the Resident and you how to appeal our decision to transfer or discharge the Resident, by requesting a hearing, and will tell you what agencies may assist you. Financial Agreement, Page 15 If the Resident is to be discharged involuntarily, we will comply with current law in making discharge or transfer arrangements. You and the Resident must cooperate and assist in the discharge planning, including cooperating with and assisting other facilities considering admitting the Resident and cooperating with governmental agencies. If you or the Facility believe that an abuse of funds contributed to the transfer or discharge for non-payment, you may, or the Facility will ask the Attorney General to investigate and make referrals to other governmental agencies. 5, Right to End This Contract. If you or the Resident decide to end this Contract and the Resident leaves the Facility, the bill becomes due and payable on the day the Resident leaves. You or the Resident must give us five days notice to terminate this contract. If the Resident leaves before the end of that time, you must still pay for each day of the required notice unless we fill the bed before the end of the notice period. In the event the Resident dies while a resident of the Facility, please designate who we should contact: elativ) or Friend: 4bda ." Funeral Home: Unless you have instructed us otherwise, we will immediately contact the individual(s) listed above to make funeral arrangements. If we are unable to reach the individual(s), we will contact the funeral home directly. 6. Additional Documents. It is not possible to cover everything that is important to the Resident's stay in our Facility in the body of this Contract. Financial Agreement, Page 16 A Therefore, we have included additional important documents as Exhibits. These Exhibits are part of this Contract. Please verify that you received all of the Exhibits and that the contents of the Exhibits were explained to you. Place your initials on the line next to the description of each Exhibit. C Exhibit 1. Obligations and Rights of an Agent. X-Exhibit 2. Private Pay: A. Items and Services Included in the Daily Rate; B. Items and Services Not Covered by the Daily Rate. Exhibit 3. A. How to Apply For and Use Medicare and Medicaid Benefits. B. Medical Assistance Nursing Facility Services (Medicaid Medical Eligibility Form) Exhibit 4. Items and Services Not Covered by Medicaid. q_-X Exhibit 5. Policies and Procedures Concerning The Resident's Personal Funds and The Resident's Personal Property. Exhibit 6. Services Provided by Outside Health Care Providers, Financial Agreement, Page 17 7. Changes In Law. Any provision of this Contract 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 Contract and, it is agreed that to the extent possible, you and the Resident and the Facility will continue to fulfill their respective obligations under this Contract consistent with the law. IN WITNESS WHEREOF, the parties have executed this Contract on this a- __ day of Qc Z? 4,f- , 20,2L) . WITNESS: By Na Tit! WITNESS: . Title: ? AGENT l (Indicate whether you are: (1) a court-appointed guardian of the property (or of the person with court granted authority to handle the Resident's funds); (2) a power of attorney appointed by the Resident; (3) a family member; or (4) other individual with access to (use, management, or control of) the income, funds and/or assets of the Resident.) Julia Manor Financial Agreement, Page 18 EXHIBIT 7 OBLIGATIONS OF THE AGENT Only an Agent may sign this Agreement. An Agent is an individual who manages, uses or controls a Resident's income, funds and assets that legally may be used to pay for the care or services that a Resident receives from a nursing facility. An Agent is obligated to use the Resident's income, funds and assets to pay the Facility for the Resident's care. The financial obligation of the Agent is limited to the amount of the Resident's income, funds and assets. The Agent assumes no personal liability for the Resident's stay at the Facility unless the Agent voluntarily agrees to be personally responsible for any payments required under this Contract which are not paid by the Resident or a third-party insurer. (See question E.1., below.) A nursing facility may not require an Agent to sign the Admissions Contract unless the applicant has been adjudicated disabled by a court or the applicant's physician has certified, in writing, that the applicant is incapable of understanding or exercising his or her rights and responsibilities. However, an Agent may voluntarily agree to sign the Admissions Contract, on behalf of an incapable applicant or at the request of a capable applicant even when the above conditions are not met. A. ONE OF THE FOLLOWING CONDITIONS MUST BE MET IN ORDER TO REQUIRE YOU AS THE AGENT TO SIGN THIS ADMISSIONS CONTRACT. (These are not required if you are signing voluntarily.) 1. Has the applicant been adjudicated disabled by a Court? Yes _ or No 2. Has the applicant's physician certified, in writing, that the applicant is incapable of understanding or exercising his or her rights or responsibilities? YQs -or No M Exhibit 1, Page 1 (NOTE: Documentation verifying the above must be included in the Resident's record if a third-party's signature is required by the Facility.) B. PLEASE INITIAL THOSE QUESTIONS WHICH DESCRIBE YOUR AUTHORITY FOR ACTING AS THE RESIDENT'S AGENT. Are you signing this Contract: - 1. At the request of the Resident? Signature verification of Resident 2. As a family member or other person with authority to manage, use or control the Residents income, funds and/or assets? 3. As a Guardian of the Property appointed by a Court? 4. As a financial Power of Attorney appointed by the Resident? (NOTE: The Agent shall provide documentation of his or her authority, where applicable,) C. AS THE RESIDENT'S AGENT, YOU HAVE CERTAIN OBLIGATIONS WHICH ARE LISTED BELOW. FAILURE TO MEET THESE OBLIGATIONS CAN RESULT IN CIVIL AND CRIMINAL PENALTIES AS DESCRIBED IN THIS EXHIBIT, INDICATE THAT YOU AGREE TO ASSUME EACH OBLIGATION BY INITIALING EACH IN THE SPACE PROVIDED, 1. I agree to pay the Facility bill in a timely manner to the extent that the Resident has income, funds and/or assets to pay for such services. Exhibit 1, Page 2 9 _2. In the event the Resident is a beneficiary of Medicare Medicaid, or any other third-party payment plan, I agree to pay all co-payments, co-insurance and deductibles, and all charges for non-covered items and services, together with any applicable late fees, to the extent of the Resident's income, funds and/or assets. A-3. In the event I have not paid a current bill to the Facility for the Resident's care, I agree to apply to Medical Assistance for a determination of the funds available to pay for the cost of the Resident's care. (NOTE: I understand if I fail to seek this determination, the Facility will seek a Court Order requiring me to do so.) 4. In the event the Resident's private income, funds and assets are exhausted during the Resident's stay, I agree to apply for Medical Assistance benefits for the Resident in a timely manner, and to cooperate fully in the eligibility process. 5. 1 agree to apply for Medicare, Veterans Administration or other third-party benefits which may be available to cover the cost of the Resident's care at the Facility. 6. In the event the Resident is applying for admission on a private pay basis, I agree to assist the Resident in providing financial information required by the Facility to determine the extent of the Resident's income, funds and/or assets. (NOTE: If it is ever determined that I knowingly or willfully participated in the disclosure of incomplete or inaccurate information, the incomplete or inaccurate disclosure is considered a breach of this Contract and the Facility reserves Exhibit 1, Page 3 the right to pursue all available legal remedies against me including, but not limited to, an action for breach of contract.) D. PENALTIES understand that I could be subject to both civil and criminal penalties for failure to meet my obligations as an Agent as follows: 1. If I willfully or with gross negligence fail to pay the required amounts from the Resident's income, funds or assets, as determined available by Medical Assistance, i understand that I could be subject to a civil money penalty for an amount at least equal to the amount due the Facility. This amount would be paid from my own funds. 2. If I willfully or with gross negligence fail to seek on behalf of the Resident all assistance from Medical Assistance which may be available to the Resident, or fail to cooperate fully in the eligibility determination process, I understand that I could be subject to a civil money penalty of up to $10,000. This amount would be paid from my own funds. 3. If I willfully or with gross negligence fail to cooperate and assist in the discharge planning process for the Resident, I understand that I could be subject to a civil money penalty of up to $10,000, This amount would be paid from my own funds. 4. If I "abuse" the Resident's funds, I understand that I could be found guilty of a misdemeanor and, on conviction, be subject to a fine of up to $10,000. This amount would be paid from my own funds. "Abuse of funds" means using the assets or income of a Resident against the express wishes of the Resident unless the expenditure was necessary for the direct and immediate welfare of the Resident. Abuse also means using the assets or income of Exhibit 1, Page 4 the Resident for the use or benefit of another unless such use is for the direct and immediate benefit of the Resident or is consistent with an express wish and past behavior of the Resident, E. IN ORDER TO PROPERLY PLAN FOR THE RESIDENT'S NEEDS, IT IS IMPORTANT THAT WE HAVE THE ANSWERS TO THE FOLLOWING QUESTIONS. PLEASE INDICATE "YES" OR "NO" TO EACH AND INITIAL. YOU ARE NOT REQUIRED TO ANSWER "YES" AND AGREE TO ASSUME RESPONSIBILITY FOR THE ISSUES ADDRESSED IN E.I. - E.7 (THESE OBLIGATIONS ARE NOT REQUIRED FOR THE RESIDENT'S ADMISSION); HOWEVER, YOU MAY VOLUNTARILY ANSWER "YES" AND AGREE ANY OR ALL OF THE FOLLOWING: TO ASSUME 1. Do you knowingly and voluntarily agree to make payments required under this Agreement from YOUR OWN RES9yRCES? Yes -/No )VO Initials _.....2. Do you agree that in the event of the Resident's death, you shall take responsibility for all burial arrangements for the Resident and for removal of all of the Resident's personal property from the Facility, subj ct to your legal authority to accept the property; Yes /No - Initials -3. If the Resident or his or her Representative wants to obtain private duty nurses or geriatric aides in accordance with the requirements of this Agreement, do you agree to be responsible to make arran-gements for those services? YesSW/No Initials -4. Payment for services of private duty nurses or geriatric aides shall be made out of the Resident's Exhibit 1, Page 5 income, funds and assets unless you agree to pay. Do you knowingly and voluntarily agree to pay for the services of private duty nurses from your own resources if these services are requested and the Resident does not have sufficient funds to pay for such servic ? Yes -/No UInitials, -5. In the event the Resident or his or her representative seeks to terminate this Contract, do you agree to give the notices required under Paragraph 5 of this Contract? Yes# /No ` Initials 6. In the event that the Resident is involuntarily discharged from this Facility, and if other arrangements cannot be made, do you agree to accept the Resident into your custody, if it is medically and legally appropriate? Yes /No - r itials RIGHTS OF THE AGENT F. YOU HAVE THE RIGHT TO COPIES OF THE FOLLOWING DOCUMENTS. DO YOU ACKNOWLEDGE RECEIPT OF THE FOLLOWING DOCUMENTS; 1. A copy of this Admission Contract; 2. A copy of Federal and State Residents' Rights; 3. A list of the Facility's charges, including the charges not included in the per diem rate; 4. A list of health care providers offering services at the facility and their current charges; and Ye../No _ Initials Exhibit 1, Page 6 THE DOCUMENTS IN F.1 THROUGH F.4 MAY BE AMENDED FROM TIME-TO-TIME CONSISTENT WITH STATE AND FEDERAL LAW AND REGULATIONS. WHEN AMENDMENTS ARE MADE, YOU WILL BE PROVIDED A COPY. G. YOU HAVE THE RIGHT TO BE NOTIFIED BY THE FACILITY OF ANY EVENT OR OCCURRENCE INVOLVING THE RESIDENT WHICH DIRECTLY AFFECTS YOUR OBLIGATION UNDER THIS AGREEMENT. 31)1 & , have read the information in this Exhibit 1. I ave had the opportunity to ask questions and I fully understand and accept all of the obligations I have in acting as the Resident's Agent. Agent Exhibit 1, Page 7 SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny R Anderson Sheriff or, ICE -HF Jody S Smith Chief Deputy Richard W Stewart Solicitor 2011 HP 26 PM 2: 22 CUMBERLAND ?C)UNTY PENNSYLVANIA Julia Manor LLC 1 vs. Tammy L. Bock Case Number 2011-7115 SHERIFF'S RETURN OF SERVICE 09/15/2011 06:41 PM - Noah Cline, Deputy Sheriff, who being duly sworn according to law, states that on September 15, 2011 at 1841 hours, he served a true copy of the within Complaint and Notice, upon the within named defendant, to wit: Tammy L. Bock as agent for Joseph R. Bock, by making known unto herself personally, at 3 Wiltshire West Street, Carlisle, Cumberland County, Pennsylvania 17015 its contents and at the same time handing to her personally the said true and correct copy of the same. NOAH CLINE, DEPUTY 09/15/2011 06:41 PM - Noah Cline, Deputy Sheriff, who being duly sworn according to law, states that on September 15, 2011 at 1841 hours, he served a true copy of the within Complaint and Notice, upon the within named defendant, to wit: Tammy L. Bock, by making known unto herself personally, at 3 Wiltshire West Street, Carlisle, Cumberland County, Pennsylvania 17015 its contents and at the same time handing to her personally the said true and correct copy of the same. SHERIFF COST: $50.44 September 19, 2011 NOAH CLINE, DEPUTY SO ANSWERS, / RON R ANDERSON, SHERIFF (c; GoUnfySuite Sheriff Telex=oft. Onr. 4 JULIA MANOR LLC t/a JULIA MANOR HEALTHCARE CENTER : Plaintiff V. JOSEPH R. BOCK and TAMMY L. BOCK, AGENT FOR JOSEPH R. BOCK and INDIVIDUALLY, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2011- 7115 CIVIL TERM CIVIL ACTION-LAW PRAECIPE TO ENTER DEFAULT JUDGMENT PURSUANT TO Pa.R.C.P. 1037 TO THE PROTHONOTARY: ti. ?T r n t z) © 6 LD ==" Please enter judgment in favor of the Plaintiff, Julia Manor LLC t/a Julia Manor Healthcare Center and against the Defendant, Tammy L. Bock, for failure to file an answer to the Complaint of Plaintiff. A true and correct copy of the Notice of Default is appended hereto as Exhibit "A." A true and correct copy of the Certificate of Mailing for the Notice of Default is appended hereto as Exhibit "B." I certify that the Notice of Default was given in accordance with Pa.R.C.P. 237.1. Plaintiff requests judgment in the amount of $37,045.00 together with attorney fees of $1,036.00 for a total of $38,081.00. Respectfully submitted, j:IC CHERER ?y d d F` ' *770 1 t?(- 0 # le-36 F ,? 66 David A. Baric, Esquire I.D. # 44853 X10 b.c P 19 West South Street / ` 1fa11E&41( Carlisle, Pennsylvania 17013 (717) 249-6873 JULIA MANOR LLC t/a JULIA IN THE COURT OF COMMON PLEAS OF MANOR HEALTHCARE CENTER : CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. NO. 2011- 7115 CIVIL TERM JOSEPH R. BOCK and TAMMY L. BOCK, : AGENT FOR JOSEPH R. BOCK CIVIL ACTION-LAW and INDIVIDUALLY, : Defendants TO: Tammy L. Bock 3 Wiltshire West Carlisle, Pennsylvania 17015 Date of Notice: October 6, 2011 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 3ARIC S HERER LL t David A. Baric, Esquire 19 West South Street Carlisle, PA 17013 (717) 249-6873 EXHIBIT "A" ?FOSULSONKEs Certificate g This Certificate of McNinp provides evidehae that mail has been presented to p ??`?. p This fomy" be used for vatic and intemetl nal mei. S q N? From: ' tjoz G. L A D ?7 ,,ui7 Te: am MO 2 Z- r-00 15 co?"'? -t_wm cn L D J D M m PS Form 3817, April 2007 PSN 7530-02-000-9065 EXHIBIT "B" CERTIFICATE OF SERVICE I hereby certify that on October 19, 2011, I, David A. Baric, Esquire, of Baric Scherer LLC did serve a copy of the Praecipe To Enter Default Judgment Pursuant To Pa.R.C.P. 1037, by first class U.S. mail, postage prepaid, to the party listed below, as follows: Tammy L. Bock 3 Wiltshire West Carlisle, Pennsylvania 17015 David A. Baric, Esquire JULIA MANOR LLC t/a JULIA i MANOR HEALTHCARE CENTER : Plaintiff v. j JOSEPH R. BOCK and TAMMY L. BOCK, AGENT FOR JOSEPH R. BOCK and INDIVIDUALLY, Defendants IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2011- 7115 CIVIL TERM CIVIL ACTION-LAW NOTICE OF JUDGMENT PURSUANT TO Pa.R.C.P. 236 TO: Tammy L. Bock 3 Wiltshire West Carlisle, Pennsylvania 17015 Notice is hereby given to you of entry of a judgment against you in the above matter. Prothonotary Date: ID 2 0 /j JULIA MANOR LLC t/a JULIA IN THE COURT OF COMMON PLEAS OF MANOR HEALTHCARE CENTER : CUMBERLAND COUNTY, PENNSYLVANIA Plaintiff V. NO. 2011- 7115 CIVIL TERM JOSEPH R. BOCK and TAMMY L. BOCK, AGENT FOR JOSEPH R. BOCK and INDIVIDUALLY, Defendants CIVIL ACTION-LAW C-) cw roCD rnrn c? rn C'7 "j PRAECIPE TO ENTER DEFAULT JUDGMENT PURSUANT TO Pa.R.C.P. 1037 TO THE PROTHONOTARY: Please enter judgment in favor of the Plaintiff, Julia Manor LLC t/a Julia Manor W Healthcare Center and against the Defendant, Joseph R. Bock, for failure to file an answer to the Complaint of Plaintiff. A true and correct copy of the Notice of Default is appended hereto as Exhibit "A." A true and correct copy of the Certificate of Mailing for the Notice of Default is appended hereto as Exhibit "B." I certify that the Notice of Default was given in accordance with Pa.R.C.P. 237.1. Plaintiff requests judgment in the amount of $37,045.00 together with attorney fees of $1,036.00 for a total of $38,081.00. Respectfully submitted, BARIC SCHERER David A. Baric, Esquire I.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 sr41. J zL 6, ?`? 7 JULIA MANOR LLC t/a JULIA MANOR HEALTHCARE CENTER Plaintiff V. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2011- 7115 CIVIL TERM JOSEPH R. BOCK and TAMMY L. BOCK, AGENT FOR JOSEPH R. BOCK CIVIL ACTION-LAW and INDIVIDUALLY, Defendants TO: Joseph R. Bock 15078 Wyndham Avenue Blue Ridge Summit, Pennsylvania 17214 Date of Notice: November 16, 2011 IMPORTANT NOTICE YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 BARIC SCHERER C ?C David A. Baric, Esquire 19 West South Street Carlisle, PA 17013 (717) 249-6873 EXHIBIT "A" uNnSDSTATES A -2 POSTAL SE 1 ® Certificate Of Mailin This Cartificale o; McAing provides avitlance Chet mail has been presented to USPS® for mMm ? ti This form From ay?(pe used(Cf?ornd?ompesrti?c ?a/nd mterratioeal mad c I G?NZA o Q r C D l 1A WaA SI)u?ln S rte m " ?,arli?e Pa 1?D13 TO: S n ?, b(%i ` CD r, c Y CD ci => CD to cn o._?..,y .? n hauvl Ryen utf ?,f-- _ -r v. in z?JO?'oo 1 {?YYII'ni'? PPC n a?? r'~? --'__wR, cn co = m PS Form 3817, April 2007 PSN 7530-02-000-9065 EXHIBIT "B" CERTIFICATE OF SERVICE I hereby certify that on December 13, 2011, I, David A. Baric, Esquire, of Baric Scherer LLC did serve a copy of the Praecipe To Enter Default Judgment Pursuant To Pa.R.C.P. 1037, by first class U.S. mail, postage prepaid, to the party listed below, as follows: Joseph R. Bock 15078 Wyndham Avenue Blue Ridge Summit, Pennsylvania 17214 David A. Baric, Esquire JULIA MANOR LLC tla JULIA MANOR HEALTHCARE CENTER : Plaintiff V. JOSEPH R. BOCK and TAMMY L. BOCK, AGENT FOR JOSEPH R. BOCK and INDIVIDUALLY, Defendants CIVIL ACTION-LAW NOTICE OF JUDGMENT PURSUANT TO Pa.R.C.P. 236 TO: Joseph R. Bock 15078 Wyndham Avenue Blue Ridge Summit, Pennsylvania 17214 Notice is hereby given to you of entry of a judgment against you in the above matter. Jfo yDate: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2011- 7115 CIVIL TERM