HomeMy WebLinkAbout12-0825t ?.:t?- g?a?= F lCL
PRCT1-I(}NOTA ;'
IN THE COURT OF COMMON PLEAS 2012 FEB - 9 Ate 9" 3 a
CUMBERLAND COUNTY, PENNSYLVANIA CUMBERLAND COUNTY
RENNSYLVANIA
COUNTRY MEADOWS RETIREMENT CIVIL ACTION - LAW
COMMUNITIES, LLC d/ b/ a
COUNTRY MEADOWS OF WEST
SHORE IV,
Plaintiff,
n Bas civil
v. No. a? pt -
JOAN GROVE individually, by and
through her agent Jay Braderman,
JAY BRADERMAN, in his capacity as
agent for JOAN GROVE, and
THERESA TYRRELL, in her capacity
as responsible party for JOAN GROVE,
Defendants. :
NOTICE TO DEFEND
Pursuant to PA RCP No. 1018.1
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
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, GO TO OR TELEPHONE THE OFFICE SET FORTH
BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING
A LAWYER.
d
2 * a -7a sy S
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE
ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY
OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Cumberland County Bar Association
32 S. Bedford Street
Carlisle, PA 17013
Phone: (717) 249-3166
Toll Free: (800) 990-9108
EN LA CORTE DE ALEGATOS COMON DEL
CONDADO DE CUMBERLAND, PENNSYLVANIA
COUNTRY MEADOWS RETIREMENT CIVIL ACTION - LAW
COMMUNITIES, LLC d/b/a
COUNTRY MEADOWS OF WEST
SHORE IV,
Plaintiff,
V. No.
JOAN GROVE individually, by and
through her agent Jay Braderman,
JAY BRADERMAN, in his capacity as
agent for JOAN GROVE, and
THERESA TYRRELL, in her capacity
as responsible party for JOAN GROVE,
Defendants. :
AVISO PARA DEFENDER
Conforme a PA RCP Num. 1018.1
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de
las demandas que se presentan mas adelante en las siguientes paginas, debe tomar
accion dentro de los proximos veiente (20) dias despues de la notification de esta
Demanda y Aviso radicando personalmente o por medic, de un abogado una
comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee
a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de
tomar accion como se describe anteriormente, el caso puede proceder sin usted y un
fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra
reclamation o remedio solicitado por el demandante puede ser dictado en contra suya
por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros
derechos importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA
SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A
CERCA DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES
POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE
AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A
PERSONAS QUE CUALIFICAN.
Cumberland County Bar Association
32 S. Bedford Street
Carlisle, PA 17013
Phone: (717) 249-3166
Toll Free: (800) 990-9108
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNSYLVANIA
COUNTRY MEADOWS RETIREMENT
COMMUNITIES, LLC d/b/a
COUNTRY MEADOWS OF WEST
SHORE IV,
Plaintiff,
CIVIL ACTION - LAW
V. No.
JOAN GROVE individually, by and
through her agent Jay Braderman,
JAY BRADERMAN, in his capacity as
agent for JOAN GROVE, and
THERESA TYRRELL, in her capacity
as responsible party for JOAN GROVE,
Defendants.
COMPLAINT
AND NOW, comes, Country Meadows Retirement Communities, LLC d/b/a
Country Meadows of West Shore IV ("Plaintiff"), by and through its attorneys,
SCHUTJER BOGAR, and files this Complaint against Defendant Joan Grove ("Defendant
Grove") individually, by and through her agent Jay Braderman, Defendant Jay
Braderman ("Defendant Braderman"), in his capacity as agent for Joan Grove, and
Defendant Theresa Tyrrell ("Defendant Tyrrell"), in her capacity as Joan Grove's
responsible party, (collectively "Defendants"), in support thereof, provides as follows:
1. Plaintiff is a corporation created and existing under the laws of the
Commonwealth of Pennsylvania, with its principal offices located at 355 S. Sporting Hill
Road, Mechanicsburg, PA 17050.
2. Defendant Grove is an adult individual who currently resides at 355 S.
Sporting Hill Road, Mechanicsburg, PA 17050 as a resident of Plaintiff's assisted living
facility.
3. Defendant Braderman is Agent for Defendant Grove, a resident of
Plaintiff's skilled nursing facility. A true and correct copy of the Power of Attorney is
attached hereto as, Exhibit "A" and incorporated by reference. Defendant Bradermari s
place of business is listed at 225 Market Street, Suite 304, Harrisburg, PA 17101.
4. Defendant Tyrrell is an adult individual who, upon information and
belief, currently resides at 315 W. Shady Lane, Suite 1, Enola, PA 17025.
5. On or about December 3, 2008, Defendants Grove and Tyrrell made
application for Defendant Grove's admission to Plaintiff's assisted living facility
("Facility")
6. Plaintiff and Defendants entered into a written Resident Agreement for
Assisted Living ("Agreement"), pursuant to which Plaintiff agreed to provide
Defendant Grove with assisted living services in exchange for Defendants' promise to
pay the specified fee by the fifteenth of each month. A true and correct copy of the
Agreement is attached hereto as, Exhibit "B" and incorporated by reference.
7. At all times relevant hereto, Defendant Grove has been and remains a
resident of Plaintiff's assisted living facility.
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8. Since August 2011, the Defendants have failed to make payment as
required under the Agreement for the care and services provided to Defendant Grove
by Plaintiff. See Account Invoice, attached hereto as Exhibit "C."
9. Currently, Defendants owe an outstanding sum of $20,187.96. See id.
COUNTI
BREACH OF CONTRACT/ MONETARY DAMAGES
10. The allegations contained in Paragraphs 1 through 8 are incorporated
herein by reference as if fully set forth at length.
11. Plaintiff has provided and continues to provide assisted living services to
Defendant Grove in accordance with the terms and conditions of the Agreement.
12. Defendants are contractually obligated to remit payment for the services
rendered by Plaintiff.
13. Defendants have breached the Agreement with Plaintiff by failing to act in
accordance with the terms of the Agreement by remitting payment each month in
exchange for the care and services provided by Plaintiff.
14. As a result, Plaintiff is currently owed a balance of $20,187.96.
[REMAINDER OF THIS PAGE INTENTIONALLY LEFT BLANK]
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WHEREFORE, Plaintiff respectfully requests this Honorable Court:
1. Enter a judgment against Defendant Grove individually, Defendant
Braderman, in his capacity as Agent for Defendant Grove, and
Defendant Tyrrell, in her capacity as Responsible Party for Defendant
Grove, in the amount of $20,187.96, plus interest, costs, and attorney's
fees; and
2. Grant such other and further relief as the Court deems necessary and
just.
Dated: Z " 7 11-7'
Respectfully submitted,
SCHUTJER BOG
By:
Kirk Sohonage
Attorney I.D. No. 77851
(717) 909-8160
1426 North 3rd Street, Suite 200
Harrisburg, PA 17102
Janice Lorrah
Attorney I.D. No. 90009
(303) 385-8483
100 Fillmore St, 5th Floor
Denver, CO 80209
Attorneys for Plaintiff
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VERIFICATION
T71e undersigned hereby verifies that the statements of fact in the foregoing
Complaint are true and correct to the best of my knowledge, information and belief. I
understand that any false statements therein are subject to the penalties contained in 18
Pa. C.S.A. § 4904, relating to unsworn falsification to authorities.
It1i. 3 , ?o+ti
Dated:
Vincent J. Miz k, nior Vice-President
Country Meadows Retirement
Communities, LLC d/b/a Country
Meadows of West Shore IV
EXHIBITA"A"
General Durable Power of Attorney
One Agent
Financial & Health Care Decisions
DURABLE POWER OF ATTORNEY
KNOW ALL PERSONS BY THESE PRESENTS THAT I, JOAN GROVE, recently
of Mechanicsburg, Cumberland County, Pennsylvania, do hereby appoint
Jay R. Braderman, Esquire
as my attorney in fact with full power of substitution, for me and in my name and on my behalf
to transact all my business and to manage all my property and affairs as I might do if personally
present, including but not limited to exercising the powers set forth below.
Durable Power of Attorney
This power of attorney shall not be affected by my subsequent disability or
incapacity. All acts done by my agent pursuant to this power during any period of my
disability or incapacity shall have the same effect and enure to my benefit and bind me
and my successors in interest as if I were competent and not disabled.
Management of Assets
1. Cash Accounts: To collect and receive any money and assets to which 1 may be
entitled; to deposit cash and checks in any of my accounts; to endorse for deposit, transfer or
collection, in my name and for my account any checks payable to my order; and to draw and sign
checks for me and in my name, including any accounts opened by my agent in my name at any
bank or banks, savings society or elsewhere; and to receive and apply the proceeds of such
checks as my agent deems best; and to act as my representative payee for all Social Security,
Medicare, and other federal and state benefits.
2. Stocks and Bonds: To take custody of my stocks, bonds and other investments
of all kinds, to give orders for the sale, surrender of exchange of any such investments and to
receive the proceeds therefrom; to sign and deliver assignments, stock and bond powers and
other documents required for any such sale, assignment, surrender or exchange; to give orders
for the purpose of stocks, bonds and other investments of any kind and to settle for same, to give
instructions as to the registration thereof and the mailing of dividends and interest; to clip and
deposit coupons attached to any coupon bonds, whether now owned by me or hereafter acquired;
to represent me at shareholder's meetings and vote proxies on my behalf; and generally to handle
and manage my investments.
3. Personal Property: To buy or sell at public or private sale for cash or credit or
by any other means whatsoever; to acquire, dispose of, repair, alter or manage my tangible
personal property or any interests therein.
4. Real Estate: To lease, sell, release, convey, extinguish or mortgage any interest
in any real estate 1 own, on such terms as my agent deems advisable, and to purchase or
otherwise acquire any interest in and acquire possession of real property and to accept all deeds
for such property; and to manage, repair, improve, maintain, restore, build, or develop any real
property in which I now have or may later acquire an interest.
5. Safe Deposit Boxes: To have access to any and all safe deposit boxes now or
hereafter standing in my name; and add to and to remove all or any part of the contents thereof;
and to enter into leases for such safe deposit boxes or surrender same.
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6. Insurance: To procure, change, carry or cancel insurance of such kind in such
amounts against any and all risks affecting property or persons against liability, damage or claim
of any sort.
7. Benefit Plans: To apply for and receive any government, insurance, or
retirement benefits to which I may be entitled and to exercise any right to elect benefits or
payment options.
8. Taxes: To prepare, execute and file in my name and on my behalf any tax
returns.
9. Employment of Others: To employ lawyers, investment counsel, accountants,
custodians, physicians, dentists, nurses, therapists, and other persons to render services for, or to
me, or my estate and to pay the usual and reasonable fees and compensation of such persons for
their services.
10. Claims: To institute, prosecute, defend, compromise or otherwise dispose of and
to appear for me in any proceedings at law or in equity.
Health Care Provisions
11. Access to My Medical and Other Personal Information: To request, review,
and receive any information, verbal or written, regarding my personal affairs or my physical or
mental health, including medical and hospital records, and to execute any releases or other
documents that may be required in order to obtain this information.
12. Consent or Refuse Consent to My Medical Care: To give or withhold consent
to my medical care, surgery or any other medical procedures or tests; to arrange for my
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hospitalization, convalescent care or home care; and to revoke, withdraw, modify or change
consent to my medical care, surgery or any other medical procedures or tests, hospitalization,
convalescent care or home care which I or my agent may have previously allowed due to
emergency conditions. I ask my agent to be guided in making such decisions by the personal
preferences I have expressed regarding such care. Based on those same preferences, my agent
may also summon paramedics or other emergency medical personnel and seek emergency
treatment for me, or choose not to do so, as my agent deems appropriate given my wishes and
my medical status at the time of the decision. My agent is authorized, when dealing with
hospitals and physicians, to sign documents titled or purporting to be a "Refusal to Permit
Treatment" and "leaving Hospital Against Medical Advice" as well as any necessary waivers of
or releases from liability required by the hospitals or physicians to implement my wishes
regarding medical treatment or non-treatment.
13. Consent, or Refuse to Consent, to My Psychiatric Care: Upon the execution
of a certificate by two (2) independent psychiatrists who have examined me, and in whose
opinion I am in immediate need of hospitalization because of mental disorders, alcoholism or
drug abuse, to arrange for my voluntary admission to an appropriate hospital or institution to
treat the diagnosed problem or disorder; to arrange for private psychiatric and psychological
treatment for me; to refuse consent for any hospitalization, institutionalization, and private
psychiatric and psychological care; and to revoke, modify, withdraw or change consent to any
such hospitalization, institutionalization and private treatment which I or my agent may have
given at an earlier time.
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14. Provide Relief From Pain: To consent to and arrange for the administration of
pain relieving drugs of any type, or other surgical or medical procedures calculated to relieve my
pain even though their use may lead to permanent physical damage, addiction or even hasten the
moment of, but not intentionally cause, my death.
15. Protect Rights of Privacy: To exercise my right of privacy to make decisions
regarding my medical treatment and my right to be left alone even though the exercise of my
right might hasten my death or be against conventional medical advice. My agent may take
appropriate legal action, if necessary, to enforce my right in this regard.
GENERAL POWERS
lb. General Authority: To do all other things which my agent shall deem necessary
and proper in order to carry out the foregoing powers which shall be construed as broadly as
possible.
RELIANCE UPON THIS DOCUMENT OR UPON THE
DECISIONS OF MY AGENT
17. Reliance on Power: This power may be accepted and relied upon by anyone to
whom it is presented until such person either receives written notice of revocation by me or a
guardian or similar fiduciary of my estate or has actual knowledge of my death. For the purposes
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of inducing any physician, hospital, or other party to act in accordance with the powers granted
in this document, I hereby represent, warrant and agree that;
a. If this document is revoked or amended for any reason, I, my estate, my
heirs, successors and assigns will hold such party or parties harmless from any loss
suffered, or liability incurred, by such party or parties in acting in accordance with this
document prior to that party's receipt of written notice of any such termination or
amendment or has actual notice of my death.
b. The powers conferred on my agent by this document may be exercised by
my agent alone and my agent's signature or act under the authority granted in this
document may be accepted by third parties as fully authorized by me and with the same
force and effect as if I were personally present, competent, and acting on my own behalf.
C. No person acting in reliance upon any representation my agent may make
regarding the scope of authority granted under this document shall incur any liability to
me, my estate, my heirs, successors or assigns for permitting my agent to exercise any
such power.
d. All third parties from whom my agent may request information regarding
my health or personal affairs are hereby authorized and directed to provide such
information without limitation and are released form any legal liability whatsoever to me,
my estate, my heirs, successors or assigns for complying with my agent's requests. With
specific reference to medical information, including information about my mental
condition, I am hereby authorizing in advance all physicians and psychiatrists who have
treated me, and all other provides of health care, including hospitals, to release to my
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agent all information and photocopies of any records which may be requested. If I have
the capacity to confirm this authorization at the time of the request, third parties may seek
such confirmation from me it they so desire. If I do not have the capacity to make such a
confirmation, all physicians, hospitals, and other health care providers are hereby
authorized to treat my agent's request as that of a legal representative of an incompetent
patient and to honor such requests on that basis. I hereby waive all privileges that may be
applicable to such information and records, and to any communication pertaining to me
and made in the course of a lawyer-client, physician-patient, psychiatrist-patient,
clergyman-penitent or sexual assault victim-counselor relationship.
e. My agent shall have the right to seek court orders mandating appropriate
acts if a third party refuses to comply with actions taken by my agent which are
authorized by this document, or enjoining acts by third parties which my agent has not
authorized.
18. Hold Harmless: All actions of my agent shall bind me and my heirs,
distributees, legal representatives, successors and assigns, and for the purpose of inducing
anyone to act in accordance with the powers I have granted herein, I hereby represent, warrant
and agree that if this power of attorney is terminated or amended for any reason, I and my heirs,
distributees, legal representatives, successors and assigns will hold such party or parties harmless
from any loss suffered or liability incurred by such party or parties while acting in accordance
wit this power prior to that party's receipt of written notice of any such termination or
amendment.
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19, Governing Law: Questions pertaining to validity, construction and powers
created under this instrument shall be determined in accordance with the laws of the
Commonwealth of Pennsylvania.
1 have signed this power of attorney this day of 2008.
A
JO. GROVE
Social Securi umber
8
ACKNOWLEDGMENT
COMMONWEALTH OF PENNSYLVANIA}
:SS:
COUNTY OF L4f 1(tA"-(-,Q }
COMMONWEALI*h vh ,-tNNSYLVANIA
NoWaf SPai
Donne E. Grkrwond, Notary Pubic
Lower Alen Twp•, 0irnberland County
My Condon t xoir-?s .lime 19, 2010
Member. PennsvNnr 3, w. ^ of Notaries
2008, personally appeared before me, a Notary
On this day of <` I ,'')A
Public in and for the said county and state, Joan Grove, known to me or satisfactorily proven to
be the same, and attests to the free and voluntary signature of foregoing durable power of
attorney,
Jo Grove
I have signed my name and affixed my seal.
Notary Public
My Commission Expires: 1 (1 ?o !
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NOTICE
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU
DESIGNATE (YOUR "AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH
MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL
PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU.
THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO
EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT
MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS
POWER OF ATTORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR
LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT
THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR UNLESS A
COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENTS AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S
FUNDS.
A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR
AGENT IS NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE
EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56.
IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND,
YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS
CONTENTS.
s /?* rinci al f e Itf ate
Jo Grove
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I, JAY R. BRADERMAN, ESQUIRE, have read the attached
power of attorney and am the person identified as the agent for the principal. I
hereby acknowlcdgc that in the absence of a specific provision to the contrary
in the power of attorney or in 20 Pa.C.S. when I act as agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from our assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and
disbursements on behalf of the principal.
(Agent)_(Date)
ERMAN, ESQUIRE
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EXHIBIT "B"
C,?gY Iff ft, 10
A
Retirement Communities
Independence • Friendship • Respect
Resit-nt JWeementfor. I ssfisted-.l'iving
Welcome to Country Meadows Retirement Communities. We
are licensed by the Commonwealth of Pennsylvania,
Department of Public Welfare, (the Department or DP99, as a
Personal Care Home (assisted living facility). This Resident
Agreement ("Agreement') spells out as simply and completely
as possible (1) the services that Country Meadows will provide
when you move into our community, (2) the charges that you
will receive for different types of services, (3) the circumstances
under which your care may need to be changed in the future,
and (4) your rights and responsibilities as a member of our
community.
This Agreement is made between Country Meadows Associates
("Community) and Joan Grove("You'). It is a self-renewing,
month-to-month Agreement that can be terminated only as
provided for under Section G. However, you or your
Responsible Person, if any, may rescind this Agreement by
delivering written notice to the Community within 72 hours of
your dated signature, and pay only for the services received.
Thank you for choosing Country Meadows. We look forward to
serving you.
A. ACCOMMODATIONS
Beginning on 1211312008 the Community, located at
Road
Street Address
Mechanicsburg PA
the following
City State zip
355 S. Sporting Hill
17050 agrees to provide you with
accommodations and level of service (please check all that apply):
® Basic Assisted Living ® Enhanced ? Windows Memory Support
? William Penn Assisted Living ? Enhanced ? Enhanced Plus
? Meadows Assisted Living ? Enhanced ? Enhanced Plus
The personal care services provided in Basic Assisted Living, William Penn and
Meadows are explained more fully in Section D, Transfer to a Different Level of
Service. "Enhanced, " "Enhanced Plus, " and "Windows Memory Support" are
explained in Section B, below.
1l1I NIA} W S)
You may occupy and use Apartment No. 2024, subject to the terms of this Agreement.
B.
PERSONAL CARE SERVICES AND CHARGES
1. Customized Service
In addition to the Apartment and programs offered in the service level selected
above, life in our Community includes the following:
• Breakfast, lunch and dinner daily in a comfortable dining room.
Dining areas can be reserved to accommodate your guests by giving
notice at least one meal in advance of the desired dining time. Guest
meals will be charged as shown in Exhibit C.
• Housekeeping
• Laundry services for bed linens, towels and personal clothing;
however there is a personal laundry charge in Basic Assisted Living.
• Educational, recreational, fire safety and Healthy Living programs
• Wellness Programs in Exhibit D
• Facilities for receiving personal mail
• Instrumental Activities of Daily Living (IADLs) as indicated in your
Assessment and Customer Support Plan
• Activities of Daily Living (ADLs) as indicated in Your Assessment
and Customer Support Plan
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• All utilities, except personal telephone and cable television
• Routine scheduled transportation for medical and dental appointments
within a ten (10) mile radius of the Community or other prescribed
range. Charges for other non-routine transportation services are shown
in Exhibit C.
• Planned activities and opportunities for Community participation, and
services designed to meet your physical, social and spiritual needs.
• Enhanced, Enhanced Plus, or Windows Memory Support, when
applicable. The Community's assessment evaluates the intensity and
frequency of the personal care services outlined in Basic Assisted
Living, William Penn Assisted Living and Meadows Assisted Living
to determine if additional, or enhanced, support is required. To meet
those additional needs, the Community provides for enhanced levels of
personal care services, "Enhanced," "Enhanced Plus," or "Windows
Memory Support." An additional monthly charge of $350 for
"Enhanced" or "Windows Memory Support" and $700 for "Enhanced
Plus," will be added to your Customized Service Rate following
receipt of notification.
2. Services and Supplies for which there is an Additional Charge
The Community offers additional services, but you will be charged for them.
These services include, but are not limited to the following:
• Guest meals
• Meal tray delivery to your Apartment'
• personal laundry in Basic Assisted Living
• newspapers
• pharmacy charges
• toiletries and personal hygiene supplies
• medical and incontinence supplies
• telephone-personal
• Cable TV-personal
For a complete list of additional services, supplies and their
charges, please see Exhibit C.
3. Customized Service Rate (CSR) \W I N bouas
Your monthly Customized Service Rate is ($3361.00) (213360)2.
The equivalent monthly rate for ® private ? shared (check
one) occupancy in this Apartment would be $ 2731.00
' The Community will serve you meals in Your Apartment free of charge if you are ill and are unable to eat
in the dining room.
2 For Office Use Only - Accounting Charge Code
Your CSR applies to the service level checked on Page 2. This amount is due
and payable one month in advance by the fifteenth (15th) day of each calendar
month, e.g., June's payment is due no later than June 15`h
Any balances unpaid for forty-five (45) days from the date of billing, including
charges for services or supplies not included under the Customized Service
Rate, will be assessed interest at the rate of one percent (1 %) per month.
Your rights to occupy and use your Apartment and to receive other services
under this Agreement are contingent on timely payment of your Customized
Service Rate.
4. Adjustments to CSR and other Charges.
The Community charges differing rates for varying levels of service. You are
entitled to receive a revised Resident Agreement and at least thirty (30) days
advance notice, in writing, if the Community increases your Customized Service
Rate (CSR) for your accommodations in your current service level or raises other
fees or charges, including those listed in Exhibit "C." A 30-day notice is not
required prior to charging a higher rate when (1) You choose to occupy a larger
Apartment or (2) an assessment indicates that you require a higher level of care as
a result of illness, injury, or decline in your physical or cognitive condition. A
written notice is required to notify you of the rate change, but the new CSR may
be effective upon the move to a higher level of care.
5. Absences from the Community and Your CSR.
You are responsible for paying your Customized Service Rate, even when you are
absent from your Apartment. When you are absent, the Community will deduct
$5.00 per day from your Customized Service Rate beginning with the sixth day of
absence.
6. Occupancy Changes and Your CSR.
1. Married Couples
The Community welcomes married couples. If you share an Apartment with your
spouse, and one of you is discharged, changes service levels, or dies during the
term of this Agreement, the remaining resident may stay in the Apartment. The
remaining resident's Customized Service Rate will be based on "private
occupancy."
H. Suitemates Who Are Not Married Couples
The Community provides for semi-private occupancy of selected apartments. If
you occupy the Apartment with a friend, relative or other suitemate, and one of
you is discharged, changes service levels, or dies during the term of this
Agreement, the remaining resident may stay in the Apartment, (1) upon agreeing
to pay the then current Customized Service Rate for "special private occupancy"
4
.,S
of the Apartment or (2) after accepting a suitemate and paying the shared
Customized Service Rate.
If, after two tries, the Community is unable to provide a suitemate satisfactory to
you, you shall have the option to occupy your Apartment privately at the "special
private occupancy" Customized Service Rate or to find, within two (2) weeks of
notice to you, a compatible suitemate who is appropriate for your service level.
If you are the remaining Resident and you wish to transfer to an Apartment
designated for "private occupancy," you may do so when one becomes available.
The then current Customized Service Rate for private occupancy will apply.
C. HEALTH SERVICES
1. Initial and Annual Medical Evaluations
You agree to have an initial medical evaluation ("Medical Evaluation") by your
physician, at least two (2) but no more than sixty (60) days before move-in, and
annually thereafter, reported on a form the Community will provide. You must
give the Medical Evaluation to the Community to retain with your resident
records.
Other Medical Evaluations may take place before your annual examination, at
the discretion of the Community or at the request of the Department, following
a hospitalization, a new diagnosis, a change in mobility needs, an injury, a
serious illness or a change in the level of care needed. The Community will
assist you in securing medical care if needed.
2. Assessment and Customer Support Plan
With your assistance, and within 15 days of move-in (within 72 hours before an
in-house transfer or within 72 hours of admission in case of residents living in a
secured dementia care unit), the Community staff will prepare an initial
assessment ("Assessment") of your needs, including mobility and medications
administration. Assessments will occur annually thereafter or sooner if your
health indicates that an Assessment should be done.
The Assessment also evaluates the intensity and frequency of the services
outlined in Basic Assisted Living, William Penn, and Meadows Assisted Living
to determine if additional, or enhanced, support is required. To
meet those additional needs, the Community provides for additional levels of
service--"Enhanced" and "Enhanced Plus" as well as "Windows Memory
Support."
Based on your Assessment, and within 30 days of move-in (within 72 hours
before an in-house transfer or within 72 hours of admission in case of residents
living in a secured dementia care unit), the Community will prepare a Customer
Support Plan ("CSP"). The CSP will describe your service or treatment needs.
The CSP also will include, among other things, specific services such as
laundry, meals, equipment, activities of interest to you, Community activities,
family contacts, and medical and dental services or arrangements. If your needs
should change, as indicated on an assessment, the Community will revise your
CSP. Additionally, if the services called for in an updated CSP change your
Customized Service Rate, this Agreement will be amended accordingly.
While the Community attempts to have a licensed nurse on campus around the
clock, this may not be possible due to illness, weather emergencies, or other
factors. At such times, a trained staff member will be in charge and a licensed
nurse will be available by telephone.
3. Medications
1. Self-Management
When You Do Not Need Assistance. If you wish to self-manage your
medications, you must be assessed by a physician, physician's assistant or
certified registered nurse practitioner regarding your ability to self-manage and
your need for medication reminders.
To be considered capable of self-management, you must: (1) be able to recognize
and distinguish your medication, (2) know how much medication is to be taken,
and (3) know when the medication is to be taken.
If you do not need assistance with medications, medications may be stored in your
apartment for self-management. Medications must be kept locked in a safe and
secure place.
When You Do Need Assistance. When the Community is responsible for
assisting you with your medications, for reasons of safety and security, all your
prescription and non-prescription medications must be stored by the Community.
II. Alert Pharmacy
Alert Pharmacy Services, Inc. (Alert) is the preferred pharmacy for the
Community. In conjunction with Alert, the Community will assist you in ordering
and storing medications prescribed for self-administration. You understand and
agree that, for safety and convenience, your medications will be placed in a
Mediset or "blister pack," and you hereby authorize Alert to be your agent in
placing your medications in such containers or packages.
While the Community encourages you to use Alert, you may request the use of an
alternate pharmacy under the following conditions:
a) the pharmacy follows the Community's medications policies;
b) the pharmacy dispenses medications in Mediset containers and
delivers them weekly to the Community;
c) on a monthly basis, the pharmacy supplies a medication
administration record (MAR) that is kept current with your
prescription medications; and
d) the pharmacy bills You directly.
You agree that if the alternate pharmacy fails to follow these policies, the
Community may revoke the exception by giving you seven (7) days' written
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notice. Requests to use an alternate pharmacy should be submitted to the
Executive Director in writing on a specified form, which is available in the
Business Office.
4. Emergency Care.
In the event of a medical emergency requiring cardiopulmonary resuscitation
(CPR), a trained staff person from the Community will perform CPR on you. If
you do not wish to receive CPR, the Community will recognize your "Do Not
Resuscitate" (DNR) order for that purpose. You understand and acknowledge
that for the Community to withhold CPR in a medical emergency, a DNR order
completed for you by a physician must be in your resident record, and you must
wear a DNR bracelet or pendant.
In addition, the Community staff may summon emergency medical services
(EMS) to assist you by calling "911" or by otherwise summoning EMS. Should
your personal physician be unavailable in an emergency, you acknowledge and
agree that the Community may engage any licensed physician to attend to you.
You hereby authorize such physician to render all such medical care that he or
she deems necessary.
D.
TRANSFER TO DIFFERENT LEVEL OF SERVICE
Your application and Page 2 of this Agreement indicate the accommodations and
services you have selected. When you need or desire personal care services not
offered in the service level that you and the Community have agreed on, such
assistance may be available elsewhere within the Community. The Community
makes available to you independent living or personal care accommodations in
separate wings or floors, either within this Community's facility or within an
affiliated facility on the same Campus:
Independent Living's
In Independent Living, the Community provides one main meal daily, weekly
light housekeeping of your Apartment, scheduled transportation to medical and
dental appointments and shopping, a social and activities program, and round-the-
clock emergency response by a trained staff member. The person responsible for
emergency response may be located in an adjacent building.
Basic Assisted Living
This level of service provides three meals daily, as well as assistance with one or
more of the following personal care services:
Activities of Daily Living (ADL's)
Medication Management
Instrumental Activities of Daily Living (IADL's)
3 The Commonwealth of Pennsylvania does not license this level of service.
7
The William Penn Program
This level of service provides all services offered in Basic Assisted Living along
with the following: a higher level of support services including assistance with
ambulation, dining, continency management, personal laundry, grooming,
personal hygiene and restorative physical care.
The Meadows Program for Alzheimer's and Related Dementia
This level provides supervised care in a secure setting. Those needing this level of
service will exhibit a degree of memory loss and/or other cognitive deficit
sufficient for the attending physician to order care in a secure physical setting. In
such a secure setting, you will have access to and must enter a 3 or 4-digit code on
a touch pad mounted on the wall to leave the Meadows wing. When residing on
this wing, you are able to leave the secure section only when accompanied by a
friend, family member or staff member who is authorized to accompany you
outside the wing. Also, you will have access to a courtyard with sidewalks during
daylight hours-except in inclement weather.
In this level of service, the Community provides all services in Basic Assisted
Living along with the following: a higher level of support services intended to
assist you in participating in a fulfilling social and activities program;
management of continency and personal hygiene; and Validation® of your
feelings, which can help to maintain self-esteem and avoid depression.
Before you can be enrolled in the Community's Meadows program, a physician
must provide a written order regarding placement in this program. This order
must be renewed annually thereafter for the duration of your stay.
Basic Assisted Living, William Penn, and Meadows Assisted Living all offer
additional levels of personal care services to assist you and to help meet your
changing needs--?"Enhanced ," "Enhanced Plus" and "Windows Memory
Support."
Enhanced Service Level. Some residents require additional support due to a
lengthy recovery from surgery, an injury or declining health. When
there is a significant change in the condition of a resident, the
Community's professional staff may do an updated assessment and,
when necessary, revise the Customer Service Plan. Enhanced support
consists of the following:
• All services available in the underlying level of service
• Revised resident assessment and updated Customer Service Plan,
indicating a need for additional assistance with activities of daily
living
• Screening for rehabilitation therapy when deemed appropriate
• Assistance with management of dietary restrictions when requested.
Enhanced Plus Service Level. Residents require Enhanced Plus services
when the Customer Support Plan indicates that additional staff support
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is necessary to carry out the services outlined therein. Such additional
support services may be required prior to transitioning to skilled
nursing care or, temporarily, following a return from skilled nursing
care. This tends to be a temporary level of service. Enhanced Plus
support consists of the following:
• All services available in Enhanced level of service
• Revised resident assessment and updated Customer Service Plan
indicating a need for additional staff support
• Availability of additional assistance daily by trained staff to assist with
greater number of ADL's or those requiring a higher level of support.
Windows Memory Support Service Level. Windows Memory Support
provides specialized support and encouragement to residents who may
feel isolated, because they are suffering from some forgetfulness or
memory loss. The Windows program consists of the following:
• All the services available in the underlying level of service
• Program coordination by staff member trained in therapeutic support
• Therapeutic activity programs designed to be appropriate for residents
with memory loss
• Structured support and regular cueing that allow residents to
participate successfully in social activity, exercise and intellectually
stimulating programs
• Brain Fitness classes using PositScience software as openings are
available and when deemed appropriate.
1. Required Transfers
When you need one or more of the types of assistance provided in another level of
service, it will be necessary for you to transfer to an Apartment in that level. The
Community will provide you and your Responsible Person or your referral agent,
if any, with a thirty (30) day written notice in advance of the reasons for the
transfer. However, based on the extent of assistance needed and/or consideration
of your health, safety and well being, and/or consideration of the health, safety
and well-being of others, your transfer could take place in less than thirty (30)
days.
The Community's staff will determine your level of service by conducting a
physical and cognitive assessment. The staff will also assist you in moving to an
Apartment at the appropriate level.
If you disagree with the Community's decision to transfer, you may consult with
an appropriate assessment agency or with your physician on the need for a higher
level of care.
If you move out of the Community before the 30 days are over, the Community
will give you a refund equal to the previously paid charges for personal care
services for the remainder of the 30-day period. The term "move out" means that
you have removed all furniture and belongings from your Apartment and that the
9
Apartment is available for another resident. The refund will be issued within 30
days from the day you move out. Your personal needs allowance, if any, will be
refunded within two business days of the day you move out.
2. Choosing not to Transfer
Should you choose not to transfer to a higher level of service within the
Community when your assessment of physical and cognitive abilities indicates the
need, the Community will attempt to support you in-house until you can make
other arrangements. Ordinarily you have a period of thirty (30) days from the date
you are notified of the need for a higher level of service to make other
arrangements. However, when the Community believes there is a significant risk
of harm to you or to other members of the Community, you may be asked to
transfer immediately.
3. Transfer to Long Term Skilled Nursing
If you require skilled nursing, it will be necessary to transfer to a long-term care
facility. (When approved by the Community, a qualified home health agency or
hospice agency may be able to provide skilled nursing services for a limited
period of time.) Your physician or the Community's staff, after conducting a
physical and cognitive assessment, will determine whether you need a higher
level of service. The Community's staff will be available to assist you in finding
an appropriate facility.
The Community does not have the capability to care for, on a consistent basis,
residents who are permanently confined to bed; have a third stage decubitus (i.e.,
bedsore); or who require a feeding tube (unless self-managed), intravenous
therapy, or services on a routine basis normally provided by a long-term care
facility. Other conditions that could require a higher level of service include but
are not limited to special dietary restrictions, dysphagia, unmanageable
incontinency, contagious diseases or psychiatric conditions that are not
manageable in the Community's personal care setting.
On its South Hills and Bethlehem campuses, the Community has long term care
facilities licensed by the Pennsylvania Department of Health to provide skilled
nursing care. As a resident of the Community, you would be offered priority
admission to one of the facilities if you need this level of care and if an
appropriate bed is available. Please understand that the Community cannot
Quarantee your admission, or date of admission, to one of its nursing centers,
nor are you under any obligation to consider or use its nursing centers.
To be considered for admission, you should contact the Admissions Director of
the appropriate facility to discuss admission requirements and to determine a
possible admission date.
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E. RIGHTS AND RESPONSIBILITIES
1. Statement of Resident Rights
By signing this Resident Agreement, you and your Responsible Person, if applicable,
acknowledge that you have received the following copy of the Statement of Residents'
Rights contained in 55 PA Code, Chapter 2600(41) of the Personal Care Home
Regulations, and the rights enumerated in Section B below - Additional Resident Rights
Guaranteed by Chapter 2600:
1) A resident may not be discriminated against because of race, color, religious
creed, disability, handicap, ancestry, sexual orientation, national origin, age or
sex.
2) A resident may not be neglected, intimidated, physically or verbally abused,
mistreated, subjected to corporal punishment or disciplined in any way.
3) A resident shall be treated with dignity and respect.
4) A resident shall be informed of the rules of the home and given 30 days
written notice prior to the effective date of a new home rule.
5) A resident shall have access to a telephone in the home to make calls in
privacy. Non-toll calls shall be without charge to the resident.
6) A resident has the right to receive and send mail.
7) Outgoing mail may not be opened or read by staff persons unless the resident
requests.
8) Incoming mail may not be opened or read by staff persons unless upon the
request of the resident or the resident's designated person.
9) A resident has the right to communicate privately with and access the local
ombudsman.
10) A resident has the right to practice the religion or faith of the resident's choice,
or not to practice any religion or faith.
11) A resident shall receive assistance in accessing health services.
12) A resident shall receive assistance in obtaining and keeping clean, seasonal
clothing. A resident's clothing may not be shared with other residents.
13) A resident and the resident's designated person, and other individuals upon
the resident's written approval shall have the right to access, review and
request corrections to the resident's record.
14) A resident has the right to furnish his room and purchase, receive, use and
retain personal clothing and possessions.
15) A resident has the right to leave and return to the home at times consistent
with the home rules and the resident's support plan.
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16) A resident has the right to relocate and to request and receive assistance, from
the home, in relocating to another facility. This assistance shall include
helping the resident get information about living arrangements, making
telephone calls and transferring records.
17) A resident has the right to freely associate, organize and communicate with
others privately.
18) A resident shall be free from restraints.
19) A resident shall be compensated in accordance with State and Federal labor
laws for labor performed on behalf of the home.
20) A resident has the right to receive visitors for a minimum of 12 hours daily, 7
days per week.
21) A resident has the right to privacy of self and possessions.
22) A resident has the right to file complaints with any individual or agency and
recommend changes in policies, home rules and services of the home without
intimidation, retaliation or threat of discharge.
23) A resident has the right to remain in the home, as long as it is operating with a
license, except as in Sec. 2600(228) of the Personal Care Home Regulations
(notification of transfer)
24) A resident has the right to receive services contracted for in the resident-home
contract.
25) A resident has the right to use both the home's procedures and external
procedures to appeal involuntary discharge
26) A resident has the right to a system to safeguard money and property.
27) A resident has the right to choose his own health care providers without
limitation by the home.
Additional Resident Rights Guaranteed by Chapter 2600
28) A resident or authorized person has the right to rescind a resident agreement
by written notice to the home within 72 hours of initial dated signature of the
agreement and pay only for services received.
29) A resident has the right to question or refuse a medication if heishe believes a
medication error may have occurred.
30) Each resident shall retain, at a minimum, the current personal needs allowance
as the resident's own funds for personal expenditure. (The current personal
needs allowance for SSI residents is $60 per month.)
31) A resident is entitled to at least thirty (30) days advance notice, in writing, of
the home's request to change the contract. If a contract specifies differing
rates for varying levels of care and a resident moves to a higher level of care
with an increase in rates, a revised contract and a 30-day notice are not
12
required prior to charging the higher rates, such as a resident who is
hospitalized and upon return to the home requires a higher level of care as a
result of illness, injury or decline in condition.
32) Prior to admission, the home shall inform the resident and the resident's
designated person of the right to file and the procedure for filing a complaint
with the Department's personal care home regional office, local ombudsman
or protective services unit in the area agency on aging, Pennsylvania
Protection & Advocacy, Inc. or law enforcement agency.
33) The home shall permit and respond to oral and written complaints from any
source regarding an alleged violation of resident's rights, quality of care or
other matter without retaliation or the threat of retaliation.
34) If a resident indicates that he(she wishes to make a written complaint, but
needs assistance in reducing the complaint to writing, the home shall assist the
resident in writing the complaint.
35) The home shall ensure investigation and resolution of complaints. The home
shall designate the staff person responsible for receiving complaints and
determining the outcome of the complaint.
36) Within two (2) business days after the submission of a written complaint, a
status report shall be provided by the home to the complainant. If the resident
is not the complainant, the resident and the resident's designated person shall
receive the status report unless contraindicated by the support plan. The status
report shall indicate the steps that the home is taking to investigate and
address the complaint.
37) Within seven (7) days after the submission of a written complaint, the home
shall give the complainant and, if applicable, the designated person, a written
decision explaining the home's investigation findings and the action the home
plans to take to resolve the complaint. If the resident is not the complainant,
the affected resident shall receive a copy of the decision unless
contraindicated by the support plan. If the home's investigation validates the
complaint allegations, a resident who could potentially be harmed or his
designated person shall receive a copy of the decision, with the name of the
affected resident removed, unless contraindicated by the support plan.
38) The telephone number of the Department's personal care home regional
office, the local ombudsman or protective services unit in the area agency on
aging, Pennsylvania Protection & Advocacy, Inc. the local law enforcement
agency, the Commonwealth Information Center and the personal care home
complaint hotline shall be posted in large print in a conspicuous and public
place in the home.
2. Community Policies.
As a residential community of persons with diverse backgrounds and preferences, it is
necessary to have a set of guidelines that ensure a pleasant and safe living environment
for everyone. Consequently, you agree to abide by and conform to the following rules,
13
regulations and policies for the operation and management of the Community and to such
reasonable amendments as the Community may subsequently adopt:
1) Absences Overnight. You are free to leave the Community at anytime unless
you reside in the Meadows area, but the Community is not responsible for any
obligations or expenses that you incur while absent.
If you plan to be out overnight or longer, you must sign out at the appropriate
place designated for signing out, so you can be accounted for in an
emergency. Also, it is your responsibility to request, in advance, any
medications that you need to take with you.
2) Alcohol Use. Alcohol may be used in moderation in your Apartment,
provided that other residents are not disturbed. Alcoholic refreshments also
may be provided at certain Community-sponsored social events. If your
doctor has given orders for no alcohol or if you are taking medications for
which consuming alcohol poses a danger, you should refrain from using
alcohol.
3) Normal Operating Hours. Normal Business Office hours are 9:00 a.m. to 5:00
p.m., seven days a week. For reasons of security, outside doors normally are
locked by 9:00 p.m. and are unlocked at 6:00 a.m. You must sign out when
leaving the Community and must sign in upon returning, so that in case of
emergency you can be accounted for.
4) C0m,21aint Procedure.
To the Community. The Community welcomes hearing from you about how
we are doing. We welcome both suggestions for improving our programs as
well as your complaints and concerns. By your signature on this Agreement,
you acknowledge that you have been informed of your right to submit oral
and written complaints regarding an alleged violation of resident rights,
quality of care or other matter without retaliation or threat of retaliation.
Complaints should be submitted to the Executive Director, or to his or her
designated person, and to receive after submission of a written complaint (1) a
status report within two business days and (2) a written decision within seven
days. Written complaints can be delivered in person or mailed to the attention
of the Executive Director at the address shown on Page 2 of this Agreement.
Additional information on complaint procedures is included under Additional
Resident Rights, Guaranteed by Chapter 2600.
At Fireside Chats. Also, the Community encourages you to participate in its
monthly Fireside Chats (held on campus), and in its Customer Satisfaction
Surveys, both of which provide an opportunity for you to ask questions, voice
concerns, and make suggestions.
To State Agencies. You may submit allegations of abuse or complaints about
violations of your rights under the Personal Care Home Regulations directly
to the Regional Adult Residential Licensing Office of the Department of
Public Welfare; to Pennsylvania Protection & Advocacy, Inc.; to the local
ombudsman; to the protective services unit of the county area agency on aging
14
office; or to your local law enforcement agency. Telephone numbers of these
agencies are posted in a location that is accessible to you and to all visitors.
5) Firearms Possession. Neither firearms, weapons nor ammunition shall be kept
in your Apartment, Your vehicle, or anywhere on the premises.
6) Fire Drills. Your participation in all fire drills is mandatory. The
Commonwealth of Pennsylvania Personal Care Regulations requires that all
residents participate in each fire drill. When the fire alarm sounds, you must
move promptly to the nearest safe exit and await instructions.
7) Meals. Dining times are listed in your Resident Directory and posted in an
appropriate place. Arrangements can be made to have a meal early or late in
the Dining Room due to your other commitments or appointments, when
advance notice has been given. Meals can be delivered to your Apartment at
no charge during an illness. In unusual circumstances, meal trays may be
requested and delivered to your Apartment for a $1.00 charge per tray;
delivery is at the close of the scheduled dining period.
8) Medical Evaluations. At the sole discretion of the Community, final
certification for admission or discharge, or for re-certification may be done by
the Community's Medical Director. Should your physician fail to return the
re-certification form in a timely manner, the Community reserves the right to
have the re-certification carried out by its Medical Director at your expense.
The Community reserves the right to designate that the evaluation be the more
extensive "Geriatric Assessment." This assessment provides relevant
information that assists the Community in determining how best to serve you
and your continuing strengths, abilities, interests and needs.
9) Safeguarding, Your Money and Personal Property. Because the Community
cannot be responsible for cash or valuables belonging to residents, we strongly
recommend that you keep only small amounts of cash on hand; items of
significant monetary or personal value should be kept off the premises in a
safe deposit box. Rings that are loose should be adjusted or removed for safe
keeping. Upon Your request, the Community will provide a locked drawer or
box to assist you in safeguarding your money and personal property.
10) Pets. The Community recognizes that pets can be important companions to
residents. If you wish to bring a small pet with you to the Community, Your
request will be considered by the Executive Director on a case-by-case basis.
Criteria include the size and location of Your Apartment, whether you have a
private Apartment, and your ability to care for your pet.
If Your request is approved, the following guidelines will apply: (a) You will
be responsible for your pet's complete care; and the pet must be relocated if
you become unable to provide this level of care; (b) the pet will reside in your
private Apartment except when taken outside for exercise; (c) if your
Apartment is damaged by your pet, the cost of repairs will be charged to you;
(d) your pet must be in good health and not aggressive to other residents; and
15
(e) if a cat or dog, you must provide the Executive Director with a current
certificate of rabies vaccination from a licensed veterinarian.
11) Radios & Televisions. You are asked to refrain from loud playing of radios,
televisions, tape recorders, DVD and CD players between 9:00 p.m. and 7:04
a.m.
12) Payments in Advance. The Community has established a special program for
residents who pay in advance, one time each year, their entire Customized
Service Rate for a twelve-month period. If you wish to participate, the
Community agrees to pay you six percent (G%) simple interest on the
unearned balance of the year's Customized Service Rate. Interest shall be
credited monthly to your account or, if our Agreement is terminated, principal
and interest shall be paid at that time. Each month during the term of the
Agreement, the Community shall charge your normal monthly Customized
Service Rate against the remaining principal balance before calculating the
interest earned. You will be provided a Form 1099 at the end of the year, if
applicable. Please note that the Community, by law, may not accept
prepayment of more than twelve (12) months' Customized Service Rate.
13) Hospitalization and Apartment Reservation. During any hospitalization, you
may hold your Apartment at the applicable daily Customized Service Rate,
less any meal credit.
14) Smoke Free and Candle Free Environment. The Community is a smoke free
environment. No smoking is permitted by residents anywhere on campus,
including in your Apartment, offices, public restrooms, common areas,
porches and Community vehicles. For fire safety, no lit candles shall be used
in your Apartment.
15) Telephone. You may find it convenient to have a private telephone in your
Apartment. As an alternative, there is a telephone that you can use for local
calls at no charge. Unless a phone card or credit card is used to pay for the
call, long distance calls made from the Community's telephone must be
reported so that you can be billed on your monthly statement.
1 b) P_ arking. If you operate or park your vehicle on the premises, you agree to
park the vehicle in an approved area, maintain the vehicle in operable
condition, and keep current all registrations, licenses, inspections, and
insurance coverage required by law.
17) Medicare Coverage. While a resident of the Community, you agree to
purchase Medicare Part B and Medicare Supplemental Insurance or HMO
Medicare Coverage whenever you are eligible for coverage.
18) Decoration and Alterations. Ordinarily, the Community will furnish your
Apartment with a basic furniture package, but you are free to furnish and
decorate your Apartment as you wish (except for window treatments), subject
to the Community's review to ensure that you comply with local and state
safety regulations. You always are encouraged to bring some personal items
such as favorite books, small items of furniture or a special bedspread.
16
You may not make any structural or physical changes to your Apartment
unless the Community expressly approves them in writing. Any such
alterations or improvements shall become the property of the Community.
You may not change any lock or add any lock or locking device to your
Apartment without the Community's prior written consent. The Community
must approve in advance any changes or modifications to your Apartment that
require the assistance of electricians, contractors or similar professionals.
19) Personal Hygiene Items. You or your family is responsible for supplying
personal hygiene items on a timely basis. These items include a toothbrush,
toothpaste, shampoo, hair spray, shaving supplies and incontinence supplies
(when applicable). If your family does not provide these articles, the
Community will order them and the charge will be added to your monthly bill.
A list of charges will be provided and made a part of your Agreement.
The Community will provide any resident who receives SSI, at no additional
charge, necessary personal hygiene items such as a comb, toothbrush,
toothpaste, soap, hairbrush, shampoo, deodorant and skin lotion.
20) Inventory of Personal Belongings. A form to assist you in planning and
recording what you wish to bring with you is included as Exhibit `W" It is a
voluntary record that would be helpful in the event you were to make a claim
on your insurance, should you choose to carry renter's insurance. You are not
required to complete this form before signing this Agreement.
21) Financial Management. The Community does not provide financial
management services. You are responsible for making arrangements for your
Responsible Person, a family member, or a financial management institution
to manage your finances.
The Community's Business Office is available to cash personal checks of up
to $50.00.
22) Medication Labeling and Storage. To avoid misidentification of medications,
state regulations require residents of personal care homes to store all
prescription medications, over-the-counter medications (OTC), and alternative
and sample medications (CAM) in their original labeled container. If you self-
administer your medications and store them in your Apartment, you must
inform the Community staff of your OTC or CAM medications and how they
are used. This is necessary to prepare your medication record for use in an
emergency.
Recognizing that many alternative medications have not received approval of
the Food & Drug Administration and further, their contents may vary
according to manufacturer, you acknowledge that neither the Community nor
Alert Pharmacy can assess the effect of CAM's on prescription medications
and agree not to hold them responsible for any harmful interaction(s) that
might occur.
17
If the Community assists you with medication management, all your OTC and
CAM medications must be ordered by a physician and, where appropriate,
placed in a Mediset.
23) Special Dietary Needs. The Community can accommodate your special
dietary needs provided you are capable of dietary self-monitoring and self-
management. The Community can assist you with dietary self-management by
providing you with information about items on our menu to assist you in
selecting the types and quantities of foods that are safe for you to eat.
24) Your Privacy and Video Recording. For the safety and security of our
residents, the Community may use video cameras to record persons, including
residents, as they enter and exit the building. In the interest of resident
privacy, the Community will not otherwise make video recordings of residents
without their permission. Video tapes may be kept for security purposes.
F. CONFIDENTIALITY AND PRIVACY POLICY
1. Access to Your Personal and Medical Records.
The relationship created with you is our most important asset. The Community fully
understands that you have entrusted us with private personal and medical information,
and we will protect the confidentiality of this information.
Any personal or medical records that the Community prepares or maintains shall be
confidential. Access is limited to the following persons: (1)You; (2) your
Responsible Person or authorized legal representative, if any; (3) staff persons for the
purpose of providing services for you; and (4) authorized agents of the local, state or
federal government.
The Community will not disclose your personal and medical records to third parties
unless one of the following exceptions applies:
• when there is an emergency;
• when there is valid written consent from (a) You, (b) an individual
holding your power of attorney for health care, (c) your health care
proxy, or (d) your responsible person; or
• when a court orders disclosure.
2. Consent to Release Records
Outside the exceptions enumerated in Paragraph F (1), the Community will not share
your personal and medical records with third parties unless you have given the
Community written authorization to do so. This Agreement serves as written consent
for the Community to release your records in the following situations:
• to Community staff and agents on a need-to-know basis;
• to Community staff to use internally to determine the
appropriateness of supportive assistance and to develop your
Customer Support Plan;
18
• to any other health care provider from whom you receive
treatment;
• to third party payors of health services provided to you; and
• to a hospital or other health care institution to which you are
admitted for treatment.
3. Access to You and to Your Apartment
Because the State and Community Service Organizations have an interest in
protecting your health and safety, these agencies, including Pennsylvania Protection
& Advocacy, Inc. (PP&A), must be given reasonable access to public areas of the
Community as well as to your Apartment. Duly authorized representatives of these
agencies, after providing identification and stating the purpose of their visit, may
enter and inspect your Apartment at any time without advance notice.
The Community's staff may enter your Apartment at reasonable times and for
reasonable purposes, including inspection, maintenance and other services described
in this Agreement. Every effort will be made to notify you when a Community
employee will enter or has entered your Apartment for non-routine events.
G. TERMINATION OF THIS AGREEMENT
1. By You.
This Agreement is a self-renewing, month-to-month Agreement. You may
terminate this Agreement at any time, with or without cause, by giving thirty (30)
days' written notice to the Community through the Community's Executive
Director. Your notice must identify the date when the termination is to become
effective. This date must be at least thirty (30) days after the date of the notice.
In addition, if you are transferred permanently to an outside facility because you
need a level of care not available at the Community, you may terminate this
Agreement immediately upon vacating your Apartment and removing all your
belongings from it. Otherwise, you owe the Community the charges for your
Customized Service Rate and any ancillary services for the entire length of the 30
day time period for which payment has not already been made.
2. By the Community.
The Community may terminate this Agreement at any time by giving thirty (30)
days' written notice to you and to your responsible person and your referral agent,
if applicable, for the following reasons:
• Your failure to pay the Customized Service Rate or additional
charges for services within forty five (45) days of the date billed;
• Your failure to comply with local or state laws after receiving written
notice of the alleged violation;
• Your failure to comply with the Community's Policies as described in
Section E (2);
19
• a change in the use of the Community or voluntary or involuntary (by
the Department) closing of the home;
• the Community's finding that the Community is inappropriate for your
care; or
• if meeting your needs would require a fundamental alteration in the
home's program or building site, or would create an undue financial or
programmatic burden on the home.
Notwithstanding the foregoing, the Community may terminate this Agreement at
any time by giving you written notice to vacate immediately if you are engaging
in behavior that poses a threat to the mental and/or physical health or safety of
yourself or others in the Community.
If the Community should close to all Residents, the Community's Executive
Director shall submit to you a written statement of the intent to close along with
the projected closing date, at least thirty (30) days before closure. Copies shall be
provided to you, to the Department of Public Welfare, to your emergency contact
or designated person, to any agencies that participated in your referral to the
Community, and to any agencies currently providing services to you. (This
paragraph is required by state regulations.)
3. Vacating Your Apartment and Your Refund.
Upon termination of this Agreement for any reason other than death, you or
your estate shall vacate your Apartment, remove all of your belongings from it,
and return all keys to the Community.
Until your Apartment is vacated and all your property is removed, you shall
remain liable for paying the Customized Service Rate.
After your Apartment has been vacated, the Community may remove any of your
remaining belongings and place them in storage or dispose of them. Any refund of
prepaid charges owed to you will be paid within thirty (30) days of when you
vacate your Apartment.
Your personal needs allowance, if any, will be refunded within two business days
of your discharge or transfer.
4. Termination and the Elder Care Payment Restitution Act
The Community acknowledges and complies with the Elder Care Payment
Restitution Act (Act 171 of 2002), which establishes a mandatory refund policy
for residents in the event of death while residing at a licensed personal care
facility. In the event of death, your estate, personal representative or guardian
shall remain liable for payment of the Customized Service Rate, less the cost of
"elder care services," until your personal belongings have been removed from the
Apartment.
Elder Care Services are defined by law as "services or treatment provided to meet
a consumer's need for personal care or health care, including, but not limited to,
homemaker services, assistance with activities of daily living, physical therapy,
occupational therapy, speech therapy, medical social services, home care aide
20
services, companion care services, private duty nursing services, respiratory
therapy, intravenous therapy, and in-home dialysis and durable medical
equipment services, which are routinely provided unsupervised and require
interaction with the consumer."
Following removal of your personal property from the Apartment, that portion of
your prepaid Customized Service Rate related to "elder care services" will be
refunded to your estate, personal representative or guardian within thirty (30) days
of the date your personal property is removed.
As provided in Act 171 of 2002, the Community must attempt to contact your
representative or guardian within 24 hours of learning of your death to arrange for
an inventory of your personal property. Following the inventory, the Community
may choose to store your property or to leave it in your Apartment. If the
Community chooses to store the property, a fee cannot be charged. If after thirty
(30) days the personal property is not claimed and disposal is being considered,
the Community must send a notice by certified mail to your estate, personal
representative or guardian giving another fourteen (14) days to claim the property.
If still unclaimed after this period, the Community is permitted, but not required,
to dispose of the property.
The above-described provisions apply, regardless of age, in the event your
Resident Agreement for Assisted Living is terminated by death. They do not
apply to those residing in Independent Living apartments or to termination of this
Agreement under other circumstances.
H. COMMUNITY FEE
Before your move-in to the Community, you must pay a Community Fee. The
Community Fee is used to help defray the costs of entering the Community and
preparing for you to be a successful resident by carrying out your initial resident
assessment and customer support plan, ordering your medications, if any, and
preparing your medication and/or treatment administration records.
The Community Fee is $2,000 for a married couple and $1,500 for a single or
unaccompanied resident.
1. Refund
When you are discharged from the Community, for whatever reason, a portion of
the Community Fee may be refundable:
• If you give the Executive Director written notice of your intent to leave or if
you are asked to leave within seventy-two (72) hours of admission, you will
receive a full refund of the Community Fee;
• If you are discharged following a stay of more than seventy-two (72) hours
but less than 90 days, you will receive a refund of $750;
21
• If you leave following a stay of 90 days or longer, the balance of the fee will
be retained by the Community'.
Married couples are eligible for refunds when both residents have left the
Community within the specified time period. Your length of stay includes the day
of admission but not the day of discharge.
As long as you continue to occupy an Apartment, your temporary absence from the
Community for personal or medical reasons (e.g., a vacation, hospital or nursing
home stay) does not amount to discharge. When applicable, the Community will
refund your Community Fee as long as you have paid your Customized Service
Rate and all other applicable charges owed at the time of discharge.
Refunds will be made within the period prescribed by state law or within thirty (30)
days of the date your apartment is vacated, whichever comes first.
In the event that your discharge from the Community coincides with your
admission to a Country Meadows long-term care facility on either the Bethlehem or
South Hills campus, you will receive a standard refund of the Community Fee as
described above. If you return to an assisted living apartment following a stay in our
long-term care facility, the Community will not require you to pay a second
Community Fee.
I. ACCURACY OF ADMISSION DOCUMENTS.
You understand and agree that your application forms, statement of finances, health
history, medical reports, medications, personal interviews, and emergency
information records, as well as copies of your Social Security card, Medicare cards,
and any pharmacy insurance plan or PACE card, if applicable, are a part of this
Agreement. Any intentional material misrepresentation or omission by you about
Your financial resources or your health or medical history shall render this
Agreement voidable at the Community's option. You agree to submit updated copies
of the above information from time to time as changes take effect.
3. NON-DISCRIMINATION POLICY
It is the Community's policy to comply with all local, state, and federal laws and
regulations. The Community does not discriminate in resident admissions or care on
the basis of race, ancestry, color, religious creed, age, sex, sexual orientation,
handicap, disability or national origin, provided the resident, in the sole opinion of the
Community, can be cared for legally and responsibly. Suitemates in shared
apartments are selected according to sex and their cognitive and physical abilities.
Otherwise, apartment assignments and transfers, as well as resident care, are carried
out without regard to race, ancestry, color, religious creed, age or national origin.
K. NO PROPRIETARY INTEREST
The rights and privileges granted to you under this Agreement do not include any
right, title or interest in any part of the personal property, land, buildings or
4 Residents admitted prior to September 2004 will receive a refund in accordance with refund policies in
effect at that time.
22
improvements that the Community owns or administers. Your rights are primarily for
services, with a contractual right of occupancy. Nothing contained in this Agreement
shall be construed to create the relationship of landlord and tenant between the
Community and you.
L. LIABILITY FOR PROPERTY DAMAGE
You agree to maintain your Apartment in a clean, sanitary and orderly condition. You
agree to reimburse the Community for repairs to your Apartment and/or damage to
carpeting, furnishings and fixtures in your Apartment beyond ordinary wear and tear,
as well as for any alterations described above.
M. SAFEGUARDING YOUR MONEY AND PERSONAL PROPERTY
The Community is not responsible for the loss of your property due to theft or any
other cause unless such loss is caused by the grossly negligent or intentional acts of
the Community, its co-workers or agents. Upon your request, the Community will
provide a locked drawer or box to assist you in safeguarding your money and
valuable personal property. Such requests should be addressed in writing to the
attention of the Executive Director.
Personal property insurance can be purchased from private agents to insure your
personal belongings while residing at the Community.
N. CAPACITY OF RESIDENT AND GUARDIANSHIP
Should you become unable to understand or communicate health care decisions and
should your physician or the Community's Medical Director determine that you are
incapacitated, the Community shall have the right to take the following step if you did
not designate a legal representative to act for you:
The Community may begin a legal proceeding in a court of competent jurisdiction to
judge your legal capacity and, when appropriate, have the court appoint a guardian.
The cost of the legal proceedings, including attorney's fees, shall be paid by you or
your estate. (Copies of powers of attorney documents should be provided to the
Community upon admission for your health information file.)
0. ENFORCEMENT OF THIS AGREEMENT
Failure of the Community in one or more instances to insist upon your strict
performance of, observation of, or compliance with any of the terms and provisions
of this Agreement shall not be construed to be a waiver or relinquishment by the
Community of its right to insist upon your strict compliance with all of the other
terms and provisions of this Agreement.
P. ASSIGNMENT
You agree not to assign your interest in this Agreement.
Q. GOVERNING LAW
This Agreement shall be governed by and construed in accordance with the laws of
the Commonwealth of Pennsylvania and shall be binding upon and benefit each of the
23
undersigned parties and their respective heirs, personal representatives, successors
and assigns.
R. SEVERABILITY
The various provisions of this Agreement shall be severable one from another. If a
court or an administrative body of proper jurisdiction and authority finds any
provision of this Agreement to be invalid, the other provisions shall remain in full
force and effect as if the invalid provision had not been a part of this Agreement.
S. ENTIRE AGREEMENT
This is the entire Agreement between you or your responsible person and the
Community relating to the Resident Agreement for Assisted Living. This Resident
Agreement supersedes all prior agreements relating to assisted living services that the
parties may have had, whether verbal or in writing.
You or your Responsible Person agree that there are no other agreements, provisions,
terms, conditions, warranties or representations, whether express or implied, other
than those expressly set forth herein.
No amendment of this Agreement shall be binding on either you or the Community
unless it is signed by the party whose interest is altered or amended.
You or your Responsible Person represent and acknowledge that in executing this
Resident Agreement you are not relying upon any representation or statement made
by any representative of the Community with regard to the subject matter, basis, or
effect of this Agreement.
T. RELEASE OF LIABILITY
It is the Community's policy that each Resident maintains his or her freedom
and independence to the greatest extent feasible. Residents are encouraged to
exercise judgment in decisions of everyday life and to make choices that enhance
the fullness and quality of their lives.
Concurrently, declines in function may occur that are gradual and not apparent
until an accident or injury occurs. You and the Community acknowledge that as
a result of such declines, older adults are more likely to have accidents, such as
falls, and are more prone to be Injured.
Recognizing this increased risk of accidents among older adults, you
acknowledge that it is not possible for the Community to prevent all Resident
fails and similar accidents that may be due to declines in strength and balance or
loss of visual acuity. Further, you agree to release and hold the Community
harmless from accidents and injuries resulting from your decisions that exercise
your freedom and independence, in spite of the higher risk of accidents.
U. NOTICES
Notices required by this Agreement shall be in writing and delivered either by
personal delivery or mail. If delivered by mail, notices shall be sent by U.S. Postal
Service, with all postage and charges prepaid. All notices and other written
communications required under this Agreement shall be addressed as indicated
24
below, or as specified by subsequent written notice from the party whose address has
changed.
IF TO COMMUNITY. Notices to the Community should be addressed to
Executive Director, at the address set forth on Page 2 of this Agreement.
IF TO RESIDENT(S). Notices to you should be addressed as follows (If notices
are to be directed to a Responsible Person and not to the Resident, please enter
that person's name and address):
Theresa Tyrrell
315 W. Shady Lane, Suite I
Enola. PA 17425
V. PERSON RESPONSIBLE FOR PAYING THE BILL (PAYOR)
If someone other than you will be responsible for paying the bills for your stay at
the Community, state regulations provide for that person to sign this Agreement
and enter his or her name and address where indicated below. Please note that,
unless they explicitly agree to do so, the Community will not attempt to impose a
personal, financial obligation on anyone other than the Resident or his or her
estate.
W. REVIEW BY YOUR ATTORNEY
This is a contract. It has numerous provisions that affect your legal rights. It
is strongly recommended that you ask an attorney to review this Agreement
and answer any questions you may have before you sign it.
X. VOLUNTARY AND AUTHORIZED EXECUTION
By signing below, you and/or your Responsible Person signify that you have
read the terms of this Agreement, fully understand its terms, are voluntarily
agreeing to those terms, and intend to be legally bound. You and/or your
Responsible Person represent and acknowledge that the Community's
Marketing Director, Executive Director or their designee has reviewed and
explained the contents of this Agreement to you. If executing as Responsible
Person, you hereby certify that you are authorized to sign on behalf of the
Resident.
Y. ACKNOWLEDGMENT THAT THE MEADOWS IS A SECURE UNIT
If Meadows Assisted Living is checked as your service level on Page 2 of this
Agreement, this paragraph applies to you. By your signatures below, you and
your Responsible Person acknowledge that the Meadows is a secure wing
requiring use of a 3 or 4-digit code entered on a touch pad mounted near the door
in order to exit the wing. Also, you understand that a physician's order for a
secure setting is required prior to moving to the Meadows.
25
IN WITNESS WHEREOF, the Community and you have executed this Agreement in
duplicate.
RESIDENT(S):
Name: Joan Grove
.S
By:
Telephone: -3070855
t`?r nq'?r c.?,??
By:
Signature of Spouse, if applicable
PAYOR OF RESIDENT'S BILL, if applicable:
Name: Theresa Tyrrell
Address: 315 W. ShadyLane, Suite I. Enola. PA 17025
I 0-/? ID
ate
Date
Relationship esident: POA
ignatur Date
RESIDENT'S RESPONSIBLE PERSON, if applicable:
Name: Theresa Tyrrell
Address: 315 W. Shadv Lane. Suite I. Enola. PA 17025
Telephone: 3070855
Relationship to Resident: POA
1,431 D?
Date
26
THE COMMUNITY:
Name: Patricia J. Hatman
Title: Director of Marketing
By: Signatu ate
27
(This page intentionally left blank)
28
ARBITRATION AGREEMENT
(PLEASE READ CAREFULLY)
This Arbitration Agreement is executed between Country Meadows Associates
(hereafter "Community") and Joan Grove (hereafter "Resident" or "Resident's
Authorized Person") in conjunction with a Resident Agreement for admission to the
Country Meadows Retirement Community and for provision of assisted living services to
Resident. The parties to this Arbitration Agreement acknowledge and agree that upon
execution, this Arbitration Agreement becomes part of the Resident Agreement for
Assisted Living, and that the Resident Agreement evidences a transaction in interstate
commerce governed by the Federal Arbitration Act.
What is Arbitration?
Arbitration is a specific process of dispute resolution utilized instead of the
traditional state or federal court system. Instead of a judge and/or jury determining
the outcome of a dispute, a neutral third party ("Arbitrator") chosen by the parties
to this Arbitration Agreement renders the decision, which is binding on both
parties. Generally, an Arbitrator's decision is final and not open to appeal. The
Arbitrator will hear both sides of the story and render a decision based on law,
fairness, common sense and the rules established by the arbitration forum selected
by the parties. Arbitration has been selected by the Community for its Resident
Agreements with the goal of reducing the time, formalities and cost of resolving civil
disputes.
It is understood and agreed by Community and Resident or Resident's Authorized
Person that any and all claims, disputes, and controversies (hereinafter referred to as a
"claim" or collectively as "claims") arising out of, or in connection with, or relating in
any way to the Resident Agreement or any service or health care provided by the
Community to the Resident shall be resolved exclusively by binding arbitration; and that
such arbitration is to be conducted at a place agreed upon by the Parties, or that in the
absence of such an agreement, at the Community; and that such arbitration shall be
conducted in accordance with the National Arbitration Forum Code of Procedure', which
is hereby incorporated into this Arbitration Agreement, and not by a lawsuit or resort to
court process. This Agreement shall be governed by and interpreted under the Federal
Arbitration Act, 9 U.S.C. Sections 1-16.
It is agreed by the Parties that this Agreement to arbitrate includes, but is not
limited to, violations of any right granted to the Resident by law or by the Resident
Agreement for Assisted Living, breach of contract, fraud or misrepresentation,
negligence, gross negligence, malpractice, or claims based on any departure from
accepted medical or healthcare or safety standards, as well as any claims for equitable
relief or claims based on contract, tort, statute, warranty, or any alleged breach, default,
' Information about the National Arbitration Forum, including a complete copy of the Code of Procedure,
can be obtained from the Forum at 800-474-2371, by email at healthcare( arb-forum.com or toll free fax at
866-7434517, or on the Internet at http:,'www.arb-forum.com_
29
negligence, wantonness, fraud, misrepresentation, suppression of fact, or inducement.
However, this Agreement shall not limit the Resident's right to file a grievance or
complaint with the Community or any appropriate government agency, from requesting
an inspection from such an agency or from appealing through the judicial system any
involuntary discharge by the Community. In addition, this Agreement shall not apply to
collection actions initiated by the Community for nonpayment of stay nor shall this
Agreement apply to any guardianship proceedings resulting from the alleged incapacity
of the Resident.
The Parties agree that damages awarded, if any, in an arbitration conducted
pursuant to this Arbitration Agreement shall be determined in accordance with the
provisions of the state or federal law applicable to a comparable civil action, including
any prerequisites to, credit against, or limitations on, such damages. Any award of the
arbitrator(s) may be entered as a judgment in any court having jurisdiction. In the event a
court having jurisdiction finds any portion of this agreement unenforceable, that portion
shall not be effective, and the remainder of the agreement shall remain effective.
It is the intention of the Parties to this Arbitration Agreement that it shall inure to
the benefit of and bind the Parties, their successors and assigns, including without
limitations the agents, employees and servants of the Community, and all persons whose
claims are derived through or on behalf of the Resident, including any spouse, sibling,
child, guardian, executor, legal representative, administrator or heir of the Resident. The
Parties further intend that this agreement is to survive the lives or existence of the Parties
hereto.
The Parties agree that all claims based in whole or part on the same incident,
transaction, or related course of care or services provided by the Community to the
Resident shall be arbitrated in one proceeding. A claim shall be waived and forever
barred if it arose and should reasonably have been discovered prior to the date upon
which notice of arbitration is given to the Community or received by the Resident and
such claim is not presented in the arbitration proceeding.
Prior Mediation.
The Parties agree that any claim or dispute relating to the aforementioned
Resident Agreement, or any other matters, disputes, or claims between them, shall be
subject to non-binding mediation when a request is made to the other by letter. Such
mediation shall be held within sixty (60) days of receipt of the letter of request at a place
within the federal judicial district where the Community is located.
Waiver of Rieht to Jury Trial and to Anneals
This Arbitration Agreement means that the Resident or their Authorized
Person will not be able to file a lawsuit in any court to resolve any disputes or claims
that he or she may have against the Community for breach of contract, property
damage or for personal injuries which occur while residing at the Community. It
30
also means that the Resident is relinquishing and giving up any rights that he or she
may have to a jury trial to litigate any claims for damages or losses allegedly
incurred as a result of personal injuries sustained while residing at the Community.
This Agreement also means that the Community is giving up any right it may have
to a jury trial or to bring such claims in a court of law against the Resident with the
exception of matters related to guardianship and nonpayment of stay. The Resident
and/or the person legally authorized to execute this Arbitration Agreement on the
Resident's behalf acknowledge and understand that there will be no jury trial on
any claim or dispute submitted to arbitration except as set forth above. The
Resident and/or Resident's Authorized Person relinquish and give up their
constitutional right to a jury trial, as well as to any appeal from a decision or award
of damages on any matter submitted to arbitration under this Agreement.
Representation by Attorney.
Resident understands and agrees that he or she has the right to be
represented by an attorney or other representative at any time during the
arbitration process.
Notice of Claims.
The Parties agree that the aggrieved Party must give written notice of any claim
subject to mandatory arbitration no later than the applicable Statute of Limitations
prescribed by law. Written notice shall be in accordance with the National Arbitration
Forum Code of Procedure. (Information about the National Arbitration Forum, including
a complete copy of the Code of Procedure, can be obtained from the Forum at (800) 474-
2371, by email at healthcare anarb-forum.com, toll free fax at (866) 743-4517, or on the
Internet at http://www.arb-forum.com.)
This is an Authorized, Knowina and Voluntary Execution.
By signing below, the Resident and/or Resident's Authorized Person signify that
they have read the terms of the Agreement, had an opportunity to ask questions,
understand its terms, are voluntarily agreeing to those terms, and intend to be legally
bound. Questions about this Agreement can be addressed to Country Meadows General
Counsel, 830 Cherry Drive, Hershey, PA 17033, or by telephone at (800) 322-3441. If
executing as Resident's Authorized Person, you hereby certify that you are legally
authorized to sign on behalf of the Resident.
Review by an Attorney.
This is a legal contract. It has provisions that affect the Resident's legal
rights, including but not limited to his or her right to a jury trial. It is strongly
recommended that you ask an attorney to review this Arbitration Agreement and,
before signing it, answer any questions you may have. By executing this Arbitration
Agreement, the Resident and/or the Resident's Authorized Person acknowledge that
31
they have been advised by the Community to consult with an attorney prior to
executing this Agreement.
Entire Agreement.
This is the entire agreement between the Resident and the Community
relating to the arbitration of certain claims arising out of the Resident Agreement
for Assisted Living. This Arbitration Agreement supersedes all prior agreements
relating to arbitration of claims that the Resident may have had with the
Community, whether verbal or in writing. The Resident agrees that there are no
other agreements, provisions, terms, conditions, warranties or representations,
whether express or implied, other than those expressly set forth herein relating to
the arbitration of claims. No alteration or amendment of this Agreement shall be
binding on either the Resident or the Community unless reduced to writing and
signed by the party against whom such alteration or amendment is asserted. The
Resident represents and acknowledges that in executing this Arbitration Agreement
he or she is not relying upon any representation or statement made by any
representative of the Community with regard to the subject matter, basis or effect of
this Arbitration Agreement.
IN WITNESS WHEREOF, the Community and the Resident or
Resident's Authorized Person have executed this Agreement in
duplicate.
RESIDENT(S):
Name: Joan Grove
(???? ?5'. S r?-?n ?icc
Hill Addre ?` ; Mechanicsbur& PA 17050
By: ?- F
U Sign a of kesident
By:
Signature of Spouse, if applicable
(Please see next page for additional signatures)
Date'
Date
32
RESIDENT'S AUTHORIZED PERSON, if applicable:
Name: Theresa Tyrrell
Address: 315 W. Shady Lane. Suite I. Enola. PA 17025
Telephone: 3070855
Relationship tVResident: POA
r 3 a?
Date
THE COMMUNITY (Please print):
Name: Patricia J. Hartman
Title: Director of Marketin
By:
Signs re Date
33
THE FOLLOWING EXHIBITS LETTERED "A" THROUGH "D," APPLY TO
AND ARE A PART OF THE RESIDENT AGREEMENT FOR ASSISTED LIVING.
EXHIBIT "A"
RESERVED FOR FUTURE USE
34
£? ;990
212MD P.p RE910W PERS. WA%M"IENTQRY • IE4
EXHIBIT "B"
PERSONAL INVENTORY OF BELONGINGS
(INSERT ABOVE-REFERENCED DOCUMENT HERE)
35
EXHIBIT "C"
CHARGES FOR SUPPLIES AND SERVICES NOT INCLUDED IN YOUR
INITIAL CUSTOMIZED SERVICE RATE (CSR)
These charges are subject to change, in which case You would receive a thirty (30)
day notice in writing before they become effective.
ITEM
CHARGE
Guest Meals Breakfast-$2.50; Lunch-$3.50;
Dinner-$6.50
Meal tray delivered to Your Apartment $1.00 Each
Meals out As charged by restaurant
Mediset Medication Containers Upon admission You will be supplied two
Mediset containers for a one-time charge of
$15.00. There is no charge for
replacements
Dry Cleaning Billed directly by cleaner selected
Laundry in Basic Assisted Living $2.00 per load
Newspapers Billed directly by dealer
Pharmacy charges Billed directly by pharmacy
Medical & Incontinence supplies Billed at current market costs
Non-Routine transportation $10.00 per half hour, when offered
Late scheduling for transportation fee
(Less than 24 hour notice) $5.00
Accompaniment to medical or dental
appointment by personal care staff member $12.50 per half hour, when available
Television: Basic cable $ per month, if applicable
Telephone: Personal Billed directly by telephone company
Enhanced Service Level* $350/month
Enhanced Plus Service Level* $700/month
Windows Memory Support Service Level*
- - - $350/month
As determined Ay assessment Continued on Page 36
36
EXHIBIT C
PAGE 2-CONTINUED
Beauty/Barber shop charges
Women's cut-$13.00 Men's cut-$10.00
Wash & Set-$14.00 Shave-$7.50
Rinse-$4.00 Hair Color-$28.00
Conditioner-$4.00 Manicure-$12.00
Permanent Wave-$45.00 Other-$
ALERT PHARMACY SERVICES, INC.
BASIC TOILETRIES PRICE LIST
This list sets forth prices to be charged to residents for any basic toiletries supplied
through the Community. It is effective as of January 26, 2006.
ITEM SIZE PRICE
Oral B soft 40 Tooth Brush 1 Brush $2.29
Crest Toothpaste 130 901 $2.21
J&J Bab Shampoo 105 ml $1.91
Suave Shampoo 450 ml $1.90
Dove Soa 2 Bars 240 gm) $2.99
Dove Liquid Body Wash 360 ml $6.08
Sure Deodorant 76 grn $3.26
Barbasol Shaving Cream 312 gin $1.47
BIC Disposable Razors 6 pack $2.15
Plastic Comb 1 Comb $1.00
Good Hair Brush I Brush $3.97
37
EXHIBIT "D"
THE COMMUNITY'S WELLNESS PROGRAMS
The Community offers not only gracious apartments in a beautiful setting, but a quality
of life through our Wellness Program to all of our residents.
Assessment Process. The Assessment Process provides a Customer Support Plan for
each resident, reflecting their health improvements as well as their needs and
personal preferences.
Levels of Service. The Community offers four levels of service that address the changing
needs and personal choices of each resident.
Rehabilitative Therapies. Rehabilitative therapies, provided by certified professionals,
are available on-campus to provide physical, occupational and/or speech therapy
called for in your Customer Support Plan. The Vitality Program, is available to
increase and/or maintain your current level of strength through supervised exercise
programs. Nautilus equipment is also available on site to use at your convenience,
enabling residents to improve strength and flexibility. The Walking Program
encourages and supports regular walking as a therapeutic exercise to stay limber
and maintain muscle strength.
Healthy Living Lectures. Lectures are provided monthly on topics that give you the
knowledge to apply wellness principles in daily living.
Living through Change Group. Regular discussion groups are led by our chaplains that
explore options for managing life's changes.
Support Groups. Support groups, led by qualified group leaders, meet on our campus to
provide residents, families and friends an opportunity to share concerns, access
speakers and gain information on specific topics such as arthritis, dementia, grief
and loss, to name only a few.
Healthy Dining Choices. Your dining menu includes "Healthier Choices," the option of
a salad bar, vegetarian entrees, and sugar-free deserts. Dinners are served with
waitress service in a dining room designed for your personal enjoyment.
Annual Medical Examinations. We arrange for an annual medical evaluation to insure
that changes in your health are identified and treated promptly.
Flu and Pneumovax Vaccinations. These vaccinations are offered by the Community to
protect residents from common strains of flu and pneumonia.
Mediset Containers. These containers are provided for residents to store medications
safely and provide a convenient way to dispense their medications.
38
Safe Living Environment. You receive peace-of-mind by living in a residence that is
protected throughout by sprinklers and electronic fire alarms.
Socialization. Residents are encouraged to participate in a Community Life Program that
provides the stimulus and variety to enjoy life and remain active. Our diverse
program offers the opportunity to participate in fun activity, be involved in the
community and develop new friends as well as entertain your family and
acquaintances.
Revised 10.20.06
39
EXHIBIT "C"
/ice
-a h.
COUNTRY MEADOWS
RE T I REM ENT CO M M U N I T I E S
Services
Country Meadows of West Shore IV
Joan Grove's Open Account Analysis
January 26, 2012
Room and Board
Pharmacy
Beautician & Personal Items
Misc.- Activities Meals Out
Misc.- Late Charge
Date Billed Amount Due
August 2011 through January 26, 2012 $ 19,230.90
August 2011 15.10
August 2011 through January 26, 2012 534.50
32.49
September 2011 through January 26, 2012 374.97
Grand Total Due $ 20,187.96
i declare and affirm that the information and representations made in the above claim
and the account are true and correct according to my knowledge, information and belief.
Senior VP- Finance
/ ? ?, Z`. ?,017fr
W rak
ig and Information Services Date
Country Meadows Home Office PHONE: 717.533.2474 FAX: 717.533.6202
830 Cherry Drive Hershey, PA 17033 www.countrymeadows.com
SHERIFF'S OFFICE OF CUMBERLAND COUNTY
Ronny R Anderson
Sheriff
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HE PR
Jody S Smith
Chief Deputy
Richard W Stewart
Solicitor
Country Meadows Retirement Communities, LLC
vs.
Joan Grove (et al.)
z;
2012 FEB 21 AF1 B: 29
CU PENN YLVAN A Y
Case Number
2012-825
SHERIFF'S RETURN OF SERVICE
02/13/2012 Ronny R. Anderson, Sheriff who being duly sworn according to law states that he made a diligent search
and inquiry for the within named defendant, to wit: Jay Braderman, but was unable to locate him in his
bailiwick. He therefore deputized the Sheriff of Dauphin County, Pennsylvania to serve the within
Complaint and Notice according to law.
02/14/2012 Ronny R. Anderson, Sheriff, who being duly sworn according to law, states that he made a diligent search
and inquiry for the within named defendant to wit: Theresa Tyrrell, but was unable to locate her in his
bailiwick. He therefore returns the within Complaint and Notice as not found as to the defendant Theresa
Tyrrell. Request for service at 315 W. Shady Lane, Suite 1, Enola, Pennsylvania 17025 does not exist.
02/14/2012 Ronny R. Anderson, Sheriff, who being duly sworn according to law, states that on February 14, 2012, he
was unable to serve a true copy of the within Complaint and Notice, upon the within named defendant, to
wit: Joan Grove. Deputies were advised, Joan Grove is not able to accept service in her current medical
state.
02/15/2012 09:26 AM - Dauphin County Return: And now February 15, 2012 at 0926 hours I, Jack Lotwick, Sheriff of
Dauphin County, Pennsylvania, do hereby certify and return that I served a true copy of the within
Complaint and Notice, upon the within named defendant, to wit: Jay Braderman by making known unto
Susan Gelber, Paralegal for Jay Braderman at 225 Market Street, Suite 304, Harrisburg, Pennsylvania
17101 its contents and at the same time handing to him personally the said true and correct copy of the
same.
SHERIFF COST: $90.45
February 23, 2012
SO ANSWERS,
RON R ANDERSON, SHERIFF
- un; y? ie Snenfl 7 •,?it o
C firs- Of the r it
William T. Tully
Solicitor 9
Dauphin County
101 Market Street
Harrisburg, Pennsylvania 17101-2079
ph: (717) 780-6590 fax: (717) 255-2889
Jack Lotwick
Sheriff
Jack Duppan
Chief Deputy
Michael W. Rinehart
Assistant Chief Deputy
COUNTRY MEADOWS RETIREMENT
Commonwealth of Pennsylvania COMMUNITIES, LLC DBA COUNTRY
MEADOWS OF WEST SHORE IV
VS
County of Dauphin JAY BRADERMAN
Sheriff s Return
No. 2012-T-0523
OTHER COUNTY NO. 2012-825
And now: FEBRUARY 15, 2012 at 9:26:00 AM served the within NOTICE &
COMPLAINT upon JAY BRADERMAN by personally handing to SUSAN GELBER 1 true
attested copy, of the original NOTICE & COMPLAINT and making known to him/her the
contents thereof at 225 MARKET ST, STE 304 HARRISBURG PA 17101
PARALEGAL
Sworn and subscribed to
before me this 16TH day of February, 2012
-)P*2
So Answers,
leAl?
By
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
Karen M. Hoffman, Notary Public
City of Harrisburg, Dauphin County
M Commission Ex fires August 17 2014
Pa.
Deputy Sheriff
Deputy: DARIN S SHE EY
Sheriffs Costs: $41.25 2/14/2012
-1-J-6 IFT
1, 1Z
IN THE COURT OF COMMON PLEAS ''
CUMBERLAND COUNTY, PENNSYLVANIA ?J` ' f`a 5 vL o?UpV T,?,
COUNTRY MEADOWS RETIREMENT CIVIL ACTION - LAW
COMMUNITIES, LLC d/b/a
COUNTRY MEADOWS OF WEST'
SHORE IV,
Plaintiff,
V.
JOAN GROVE individually, by and
through her agent Jay Braderman,
JAY BRADERMAN, in his capacity as
agent for JOAN GROVE, and
THERESA TYRRELL, in her capacity
as responsible party for JOAN GROVE,
Defendants.
No. 2012-825 Civil
PRAECIPE TO WITHDRAW, DISCONTINUE, AND END
TO THE PROTHONOTARY:
Pursuant to the provisions of Rule 229(a) of the Pennsylvania Rules of Civil
Procedure, kindly mark the above-captioned action that was filed with your office on
February 9, 2012, as withdrawn, discontinued, and ended, with prejudice.
March 9, 2012
Respectfully submitted,
Country Meadows Retirement
Communities, LLC d/b/ a
Country Meadows of West
Shore IV
By its attorneys,
SCHUTJER BOGAR
Janice Lorrah
Attorney I.D. No. 90009
(303) 385-8483
100 Fillmore Street, 5h Floor
Denver, CO 80209
Attorneys far Plaintiff
Attorney I.D. No. 77851
(717) 909-8"160
1426 North 3rd Street, Suite 200
Harrisburg, PA 17102
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Praecipe to
Withdrazr, Discontinue, and End was served first-class, United States mail, postage
prepaid, upon the following:
Theresa Tyrell
315 W. Shady Lane, Suite 1
Enola, PA 17025
Jay Braderman on Behalf of Joan Grove
225 Market Street
Suite 304
Harrisburg, PA 17101
Counsel for Defendant
Dated: 3 l B
Lara Miller, Paralegal