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HomeMy WebLinkAbout04-4776 HCR MANORCARE, INC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO, 2004-1.t-r:KP CIVIL TERM DEBORAH 1. JOHNSON, aIkIa DEBRA J. JOHNSON, Defendant. CIVIL ACTION-LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court, your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAYBE 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 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 HCR MANORCARE, INC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004- CIVIL TERM DEBORAH J. JOHNSON, aIkIa DEBRA J. JOHNSON, Defendant. CIVIL ACTION-LAW COMPLAINT NOW, comes HCR ManorCare, Inc., ("ManorCare"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets forth the following: L HCR ManorCare, Inc. is an Ohio corporation duly authorized to conduct business in the Commonwealth of Pennsylvania with a business address of 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania. 2. Defendant, Deborah J. Johnson, aIkIa Debra J. Johnson, is an adult individual who resides at 25 Savo Avenue, Lancaster, Lancaster County, Pennsylvania. 3. By a Power of Attorney dated November 26, 2002, Jean E. Albright appointed Deborah J. Johnson as her attorney-in-fact. A true and correct copy of the Power of Attorney is attached hereto as Exhibit "A" and is incorporated by reference. 4. ManorCare owns and operates a skilled nursing facility located at 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania ("facility"). 5. On or about November 27,2002, Jean E. Albright sought admission to the ManorCare facility. 1 6. In connection with seeking admission, Deborah 1. Johnson met with ManorCare employees at the facility in Camp Hill and she executed an Admission Agreement by and through her power as attorney in fact for Jean E. Albright. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "B" and is incorporated by reference. The Admission Agreement was signed at the facility in Camp Hill. 7. Jean E. Albright became a resident of the facility on November 27, 2002 and remained a resident until the time of her death on November 16,2003. 8. On or about November 19, 2002, Jean E. Albright completed an Application for Residency provided by ManorCare. A true and correct copy of the Application for Residency is attached hereto as Exhibit "C" and is incorporated by reference. 9. In the Application for Residency, Jean E. Albright represented she was receiving Social Security income of$I,500,OO per month as of November, 2002. 10. From the date of her admission on November 27, 2002 through the date of her death on November 16, 2003, the social security benefits of Jean E. Albright were being received by Deborah J. Johnson. Upon information and belief, these receipts totaled in excess of $18,000.00. II. Upon her admission to the facility, Jean E. Albright made application for medical assistance to pay a portion of her monthly costs of care at the facility. 12. Deborah J. Johnson failed and refused to provide the information requested by the Department of Public Welfare, County Assistance Office necessary to make a determination of benefit eligibility. 2 13. As a consequence of this refusal to provide the necessary information, the County Assistance Office denied benefits to Jean E. Albright. 14. A second application was made to the County Assistance Office and Jean E. Albright was deemed eligible for medical assistance benefits effective August 1,2003. 15, As a result of the failure to provide the requested information, when medical assistance benefits were finally granted in August, 2003, the Department of Public Welfare would not make the benefits retroactive to the date of admission. 16. The Admission Agreement provides, in relevant part, as follows: 1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. COUNT I-BREACH OF CONTRACT HCR MANORCARE, INC. v. DEBORAH J. JOHNSON 17. Plaintiff incorporates by reference paragraphs one through sixteen as though set forth at length. 18. All conditions precedent to recovery under the Admission Agreement have been fulfilled. 19, Deborah 1. Johnson was obligated to use the assets and income of Jean E. Albright to satisfY the debt due and owing to ManorCare for the services and care provided to Jean E. Albright by ManorCare. 20. The amount due and owing is not covered by a third party payor. 3 21. Deborah J. Johnson has breached the Admission Agreement by failing and refusing to pay for the services and care provided from the assets and income of Jean E. Albright. 22. Late fees on the amount owed calculated from January 1, 2004 to September 1, 2004 are $2,091.08 and will continue to accrue at the per diem rate of$8.57. WHEREFORE, Plaintiff requests judgment in its favor and against the Defendant for the sum of$17,395.28 plus late fees of$2,091.08 and any additional amount of late fees accruing to the date of award, costs and expenses and attorney fees. COUNT II-MONEY HAD AND RECEIVED HCR MANORCARE, INC. v. DEBORAH J. JOHNSON 23. Plaintiff incorporates by reference paragraphs one through twenty-two as though set forth at length, 24. During the period of Jean E. Albright's residency at the facility, Deborah 1. Johnson received the sum of at least $18,000.00 in social security benefits paid to Jean E. Albright. 25. The proper use of these funds would have been to pay the costs of care accruing for the care of Jean E. Albright at the facility. 26. At the time of receipt of these funds, Deborah J. Johnson knew she was obligated to pay these funds over to ManorCare for the costs of Jean E. Albright's care at the facility. 27. Deborah J. Johnson gave no consideration for the funds of Jean E. Albright received by Deborah J. Johnson. 28. Demand has been made upon Deborah 1. Johnson to tender the funds of Jean E. Albright and she has failed and refused to do so. 4 WHEREFORE, Plaintiff requests judgment be entered in its favor and against Deborah 1. Johnson requiring her to: a) return the subject matter in specie; b) pay over the value if Deborah J. Johnson has consume the money in beneficial use; c) pay its value if Deborah 1. Johnson has disposed of the funds received; and d) award costs, expenses and interest. Respectfully submitted, David A. Baric, Esquire I.D. 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Attorney for Plaintiff dab.dir/manorcare/albright/complaint.pld _.... .......c.I.... l:l: 21 71 72495755 aBS PilGE 08 VERIFICATION The statements in the foregoing Complaint are based upon information which has been assembled by my attorney in this litigation. The language of the statements is not my own. J have read the statements; and to the extent that they are based upon infonnation which I have given to my counsel, they are true and correct to the best of my knowledge, information and belief. Ilmderstand that false statements herein are made subject to the penalties of 18 Pa.C.S. 9 4904 relating to unsworn falsifications to authorities. DATE: 0..-\-0'--( ~~ Helen Moloney RUG 31 2004 16:15 7172495755 PRGE.08 G:'Users\ljo'GGK\albright.jean,poa_wpd:ll 21 0;: POWER OF ATTORNEY 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 O~ YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND ll\ ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSL Y LIMITTHEDURA TION OFTHESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEP ARA TE FROM YOUR AGENT'S FUNDS. A COURT CAN TAKE A WAY 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 P A. 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. Dated: \ \ . a.. <:,- () ~ her Jean E. X' Albright mark I, Jean E. Albright, of820 Lisbum Road, Apartment 806, Camp Hill, P A 17011-7106 do hereby appoint Debra J. Johnson 2S Savo Avenue, Lancaster, PA 17601-3937 as my attorney-in-fact with power to transact any business at all in my name as though I myself were acting. , This power includes, but is not limited to, the following: \ 1. To write checks, and to execute and deliver payment and withdrawal orders on any accounts that I may have with any bank or other similar institution, and to deliver the checks or money paid or withdrawn to any person, group of persons, or associations; and to endorse checks or other instruments for deposit or collection; 2. To take all lawful steps to recover, collect and receive any amounts of money now or hereafter owing or payable to me, and to compromise and execute releases or other sufficient discharges for them; EXHIBIT w I1W 3. To withdraw and receive the income or corpus of any trust; 4. To sue and settle suits of any kind in my name or for my benefit; 5. To buy, sell, mortgage, hypothecate, or grant security interests in any kind of tangible or intangible personal property; - 6. To sign, assign or endorse any security issued by any corporation, bank or other organization and to exercise any rights with respect thereto that I may have; 7. To lease, sell, release, convey, extinguish or mortgage any interest in real property on such terms as may be deemed advisable; and to manage, repair, improve, maintain, restore, build or develop such property; 8. To purchase or otherwise acquire any interest in and acquire possession of real property and to accept all deeds and other assurances in the law for such property; 9. To execute, deliver, and acknowledge deeds, deeds of trust, covenants, indentures, agreements, mortgages, hypothecations, bills of lading, bills, bonds, notes, receipts, evidences of debts, releases and satisfactions of mortgage, judgmenl, ground rents and other debts; 10. To enter my safe deposit boxes and to open new safe deposit boxes, and to add to or remove any of the contents of any such safe deposit boxes, and to close out any of the boxes; II. To borrow money for my account on whatever terms and conditions may be deemed advisable, including the right to borrow money on any insurance policies issued on my life for any purpose, and to pledge, assign, and deliver such policies as security; 12. To make limited gifts. lfmy foreseeable needs are amply provided for, rny Agent may make gifts for me and on my behalf in amounts not in excess of and in a rnanner to qualify for the aQnual exclusion from Federal Gift Tax permitted under Section 2503(b) of the IRC; provided that the permissible donees shall be limited to my spouse and my issue. My Agent may make gifts to anyone or more of such donees either outright or in trust. In the case of a gift to a minor, such gift may be made in trust or in accordance with the appropriate state Uniform Transfers to Minors Act or similar statute. In the case of a gift made in trust, my Agent may execute a trust agreement for such purpose, designating one or more persons (including my Agents) as the original or successor trustees, or may make additions to an existing trust. No transfer agent, depository or other third party acting in good faith shall have any responsibility to see to the proper discharge by my Agent of any duties hereunder. In making any gifts, my Agent need not treat the donees equally or proportionately and may entirely exclude one or more persons; 2 13. To prepare, execute and file all tax retumsrequired to be made by me, to pay the taxes due, to collect any refunds, to sign waivers extending the period for the assessment of such taxes or deficiencies in them, to sign consents to the immediate assessment of deficiencies and acceptances of proposed overassessments, to execute closing agreements, and to engage and appoint attorneys to represent me in connection with any matters arising before any federal, state or local ta.xing agency; 14. To disclaim any interest in property; 15 . To renounce fiduciary positions; 16. To arrange for my entrance to and care at any hospital, nursing home, health center, convalescent home, retirement home, or similar institution, and to arrange for, consent to, waive and tenninate any and all medical and surgical procedures on my behalf, including the administration of drugs, and to pay all bills for my care; 17. To create a trust for my benefit and to make additions to an existing trust for my benefit. 1 do hereby ratify and confirm all that my attorney-in-fact and a substitute or successor shall lawfully do, or cause to be done, by virtue of this Power of Attorney. This Power of Allomey shall not be affected by my physical or mental disability or incapacity or by uncertainty as to whether I am dead or alive, and it may be accepted and relied upon by anyone to whom it is presented until such person either (1) receives written notice of revocation by me or a guardian (or similar fiduciary) of my estate, or (2) has actual knowledge of my death. My ~ttorney-in-fact shall be entitled to reasonable compensation for services perfonned hereunder. IN WITNESS WHEREOF, I, Jean E. Albright, being unable to sign my name because of i!\ health, ha~e td~mY named subscribed for me in the presence and at my direction by W _C _ ~ (""~, whereupon I have made my mark, unassisted, in the space between my names this \.0 day of November 2002. her Jean E.X Albright(SEAL) mark ~ ,) On this il(P day of November 2002, Jean E. Albright, the above-named individual, in our presence, declared the preceding instrument, consisting of this and three (3) other typewritten pages, to be her Letter of Attorney and being unable to sign her name hereto because of ill health directed her name to be subscribed for her which the undersigned, '\).o'sh-'\{\. J . ~,did subscribe as directed in the presence of Jean E. Albright, - in our presence, unassisted, make her mark or cross in the space provided between her names and we, in the presence of Jean E. Albright, and in the space provided between her names, and we, in the presence of Jean E. Albright, and in the presence of each other, at the request of Jean E. Albright, have subscribed our names as witnesses. /.: 4~~- residing at 4 art "0 h ,~~~.J (.... residing at ~tflx;;/'"",;; /7r -.:('(I~ & \.~ '.5::> residing at ~ ~\\~, \l~ COMMONWEALTH OFPENNSYL VANIA ) ) SS: COUNTY OF LANCASTER ) On this, the ;t(.e day of November 2002, before me, a Notary Public, personally appeared Jean E. Albright, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that she executed the same for the purpose therein contained~ , IN WI1NESS WHEREOF, I hereunto set my hand and official seal. I NOTARIAL SEAL \..j) r \ \. f, \ I I - lINOA l. WEAVER. Notary Pu~lIcO\ /vY\CM 0\. ~ lower AII.n Twp,. Cumberland Co.. PA Notary Public , ,. ''''''",Issien expires Oct. 132003 ~.~~~, ...-'.....0.... 4 ,_, AGENT'S ACKNOWLEDGMENT 1, Debra J. Johnson, have read the attached Power of Attorney and am the person identified as the agent for the principal. 1 hereby acknowledge that in the absence of a specific - provision to the contrary in the Power of Attorney or in 20 Pa. C.S. when I act as agent: 1 shall exercise the powers for the benefit of the principal. 1 shall keep the assets of the principal separate from my assets. 1 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. Dated: \\'J.({,.~';)., D~a ~fuhnsJ ~ L HCR Manor Care Pennsylvania ADMISSION AGREEMENT This Agreement is entered into by and among, d.b.a. HCR Manor Care, ("HCR Manor Care"), the Resident, and the Responsible Party, if any, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center"). Center: HCR ManorCare-Camp Hill Resident: Jean E. Albright Legal Representative: Debra Johnson Deposit: $ P Admission Date: II/27/02 Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGHTS AND RESPONSffiILITIES OF THE RESIDENT 1.01 Room and Board Rate, For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt, The Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care Organization (see Section 1.06). 1.02 Ancillary Charp:es. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or persona! care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for persona! care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. [xfllBIl "B" 1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. I. 04 Independent Providers. The Resident shall be directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program, The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents, The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program( s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: ,j Medicare, ./ Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents, For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room ,and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Payors and Managed Care Organizations, If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been detennined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notifY the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notifY the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility detennination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal Representative to notifY the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information, The Resident and/or Legal Representative agree to provide the Center with notice within five (5) days of the Resident's disenroIIment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits, It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This 3 Agreement serves as a written notice that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. 1.11 Personal Physician, The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name ofhislher personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Phannacy. The Resident and/or Legal Representative acknowledge the right to choose a phannacy of choice, provided the pharmacy selected is properly licensed, packages and supplies phannaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distribution system similar to the Center's ancillary phannacy's medication distribution system. ll. RIGHTS AND RESPONSffiILITY OF THE LEGAL REPRESENTATIVE 2.01 Legal Authority. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Legal Representative agrees to pay promptly /tom the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and charges provided for in this Agreement. 2.03 Requested Items. The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notifY the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notifY the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 4 2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such infonnation about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2,06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition pennits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Responsibilities, The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. IlL RIGHTS AND RESPONSmILITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3,02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. <The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the first month ofthe Resident's stay at the Center. 3.04 Refunds, Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days ofthe Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Infonnation. The Resident and/or Legal Representative hereby consents to the release of hislher medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third party payor or managed care organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance 5 reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identifYing the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses ofthe photograph for Center and staff to identifY the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D, c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. f. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds 6 Authorization and any other related documents. See Attachment H-I and H-2, g. The Center's policy and procedure on bedholds, election of bed holds and readmission. See Attachment I (Center Supplement), h, Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). 1. Name, address and phone number of Ombudsman, See Attachment I (Center Supplement). J. The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). k. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center, See Attachment I (Center Supplement). I Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property, See Attachment I (Center Supplement). m. The Resident Handbook. See Attachment 1. n. ResidentlPatient Rights. See Attachment K. o. MedicarelMedicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct hislher medical treatment. See Attachment M-I and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. 7 s. ASM Form. See attachment p, t. See Attachment Q. u. See Attachment R v. See Attachment S. w. See Attachment T. x. See Attachment U. y. See Attachmertt V. z. See Attachment W. 4.05 Assignment of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least ~ (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4,07 Indemnification, The Resident shall defend, indemnif'y and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property 8 of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federa!law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law, THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEm SATISFACTION. Signature of Resident: Date: Signature of Leg a! Representative, if signing on behalf of Resident: \:2J~ ~ ~~~ Date: \\''d.)-(j~ Signature ofLega! Representative, signing on hislher own behalf: Date: Center Representative: ~ S\o~\ Date: , I /21l 0 <.. 9 ATTACHMENT A ROOM AND BOARD RATE The Resident shall pay the following monthly rate: Semi-Private Room: Private Room: 3-Bed Room: 4-Bed Room: Subacute Semi-Private Room: Subacute Private Room: 3-Bed Room: 4-Bed Room: The rate of interest assessed on overdue accounts is 1.5%, the highest amount permitted by state law in Pennsylvania. 10 ATTACHMENT B ANCll,LARY CHARGES The services and supplies categorically described on this Attachment are not included in the basic Room and Board Rate, Therefore, the Resident will be individually billed for these items in accordance with Section 1.02 of the Admission Agreement. A complete list of ancillary items, together with the current price, is on file at the Center's business office. Personal laundry and dry cleaning. Personal care items, such as toothbrush, toothpaste, mouthwash, deodorant, hairbrush, Efferdent, tissues, razors, etc. Beauty and Barber Shop services Tobacco and smoking supplies, newspapers and periodicals Stationary, postage, and writing implements Radios, televisions, cable service, room telephone Transportation for non-medical purposes and ambulance charges Photocopies of medical records Personal physicians and specialists Dental services and Dentures Optometrist/Ophthalmologist services and Eyeglasses Podiatry services Special nursing services, such as hand feeding, and care for catheters, decubiti, incontinence, isolation and dressings Therapy services, including physical, speech, occupational, audiology and respiratory therapy Prescription and non-prescription medication Laboratory and x -ray tests Oxygen and related supplies IV Therapy and supplies Peritoneal dialysis Tracheotomy supplies Ventilator rental and related supplies Medical supplies, including but not limited to syringes, dressings, catheters, colostomy bags, tubes, surgical stockings, and all other supplies necessary for the treatment, nursing care, or well-being of the Resident Incontinence supplies Special equipment (for some items, a rental, rather than purchase fee is charged), such as wheelchairs, wheelchair pad, trapeze, canes, geri-chair, special mattresses, porta-chairs, etc. Special, supplementary, or very low calorie prescription dietary products, including liquid for gastric and naso-gastric tubes, and any supply necessary to accomplish special feedings, II ATTACHMENT C AUmORIZATION FOR RELEASE OR REVIEW OF MEDICAL INFORMATION 12 1/( R lillI/oJ' ( IIJ',' Authorization for Release or Review of Medical Information Authorization is hereby granted for a: Record Review Name of Reviewer Release ofInformation To: From: Patient's Name: Albright, Jean E Patient's Name Albright, Jean E Admission Date II/27/02 Discharge Date I' Ll D.O.B. 5/3/16 Copies Requested Final Diagnosis Diagnosis Summary History and Physical Examination X-Ray Reports EKG Reports Laboratory Reports Nursing Notes . Physical Orders Psychiatric Other (please SpecifY) This consent will expire on or sixty days after the date below or sooner, at my discretion. Patient's Signature Date "Gua~~lD_~Rt'fP'W~Signature Date \\\21\0<- Witness SignatuJ ~ Date ....., .)...,.~ '&~ l\\'Z.."0 < "This signature is nmssary only when the patient has a guardian or is unable to sign I Resident Name: Albright, Jean E Medical Record #: 131O 13 .- AUTHORIZATION FOR PAYMENT OF BENEFITS RESIDENT'S NAME: Albriaht. Jean E ADMISSION DATE: 11/27/02 SOC. SEC. NUMBER: 187-oS-0089 MEDICARE NUMBER: 1870S0089A I, Albrioht. Jean E. authorize and request my insurance company, third party payer or governmental payer to pay directly to HCR ManorCare-Camp Hill for nursing care benefits rendered to me or my named dependent. The type of services requested are: skilled nursing facility 1 nursing facility 1 needed ancillary services. I also authorize the release of medical information necessary to process this claim. I understand that this authorization applies to those eligible charges for which I am covered by my insurance company's benefit or third party payer and that any additional and/or denied charges are entirely payable by me. A copy of this will serve as an original. Signature of Resident Date ~~. ,J>" ~ h ,.1v~ And/Or Legal Repre~ntJve \\.1,-O-:{ Date (Copies to ResidentlLegal Representative and Center.) I Resident Name: Albright. Jean E Medical Record Number: 1310 15 ATTACHMENT E SOCIAL SECVRITY ADMINISTRATION APPOINTMENT 16 lieN lllll/o/' ( 11/'1' SOCIAL SECURITY ADMINISTRATION NAME (Claimant) (Print or Type) Albright, Jean E SOCIAL SECURITY NUMBER 187-05-0089 SOCIAL SECURITY NUMBER WAGER EARNER (if different) Section I APPOINTMENT OF REPRESENTATIVE I appoint this individual th.", \)e,,\ce\ Jlr ~'\\h- ( Name and address) to act as my representative in connection with my claim or asserted right under: D Title II D Title XVI D Title IV FMSHA ~ Title XVIII (RSDI) (SSI) (Black Lung) (Medical Coverage) I authorize this individual to make or give any request or notice; to presen r elicit evidence; to obtain information; and to receive any notice in connection with my pending claim or asserted right wholly in my ~i':';:{Cl1~ ~"' ~.~ 1...."..\<< ~~ TELEPHONE NU B DATE (AreoCode) '\\"\- r;",'\- \"'''''1 \\.~\- 1::\ ~ Section II ACCEPTANCE OF APPOINTMENT I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not, as a current or former officer or employee of the United States, disqualified from acting as the claimant's representative; and that I will not charge or receive any fee for the representation unless it has been authorized in accordance with the laws and regulations referred to on the reverse side hereof. In the event that I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Section III satisfies this requirement.) 1 am a/an (Attorney, union representative, relative, law sludenI, etc.) SIGNATURE (Representative) ADDRESS TELEPHONE NUMBER DATE (Areo Code) Section 1/1 (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under Section 206 of the Security Act, and I release my client (the claimantl from any obligations, contractual or otherwise, which may be owed to me for services 1 have performed in connection with my client's claim or asserted right. I SIGNATURE (Representative) I DATE WAIVER OF DIRECT PAYMENT I ONLY waive my right to direct certification of a fee from the withheld past-due benefrts of my client (the claimant). I do NOT, however, waive my right to petition for and be authorized to charge and collect a fee directly from my client. I SIGNATURE (Representative) I DATE Form SSA.1686-lJ4 (3"') (Saa Important 'n(onnation on Back of Last Copy) 17 HOW TO COMPLETE THIS FORM Print or type your full name and your Social Security number. Section 1 - APPOINTMENT OF REPRESENTATIVE You may appoint as your representative an attorney or any other qualified individual. You may appoint more than one person, but see 'The Fee You Owe The Representative(s).' You may NOT appoint as your representative an organization. the law firm, a group, etc. Example, you go to a law firm or legal aid group for help with your claim, you may appoint any attomey or other qualified individual from that firm or group, but NOT the firm or group itself. Check the block(s) for the program in which you have a claim. Title II, check if your claim concems disability or retirement benefrts, etc. Title XVI, check if the claim concerns Supplemental Security Income (SSI) payments. Title IV FMSHA (Federal Mine Safety and Health Act), check if the claim is for black lung benefits, Title XVIII, check only in connection with a proceeding before the Social Security Administration involving entitlement to medicare coverage or enrollment in the supplementary medical insurance plan (SMIP). More than one block may be checked, Section II - ACCEPTANCE OF APPOINTMENT The individual whom you appoint in Section I above completes this part. Completion of this section is desirable in all cases, but it is mandatory only if the appointed individual is not an attomey. 1. When will the representation stop: We will stop recognizing or dealing with your representative when (1) you tell us that he/she is no longer your representative; (2) your representative does anyone of the following: (a) submits a fee petition, or (b) tells us that he/she Is withdrawing from the claim, or (c) he/she violates any of our rules and regulations, and a hearing is held before an administrative law judge (designated as hearing officer) who orders your representative disqualified or suspended as a representative of any Social Security claimant. 2. The fee you owe the representative(s): Every representative you appoint has a right to petition for a fee. To charge you a fee, a representative must first file a fee petition with us, Irrespective of your fee agreement, you never owe more than the fee we have authorized in a written notice to you and your representative(s). (Out-of- pocket expenses are not included). If your claim went to court, you may owe an additional fee for your representative's services before the court. 3. How we determine the fee: We use the criteria on the back of the fee petition (Form SSA 1560-U4), a copy of which your representative must send you. Section III (Optional) - WAIVER OF FEE This section may be completed by your representative if he/she will not charge any fee for services performed in this claim. If you had appointed a co-counsel (second representative) in Section I and he/she will also not charge you a fee, then the co-counsel should also sign this section or give a separate waiver statement. GENERAL INFORMATION 1. When you have a representative: We will deal directly with your representative on all matters that affect your claim. Occasionally, with the permission of your representative, we may deal directly with you on specific issues. We will rely on your representative to keep you informed of the status of your claim, but you may contact us directly for any information about your claim, 2. The authority of your representative: Your representative has the authority to act totally on your behalf. This means he/she can (1) obtain information about your claim the same as you; (2) submit evidence; (3) make statements about facts and provisions of the law; and (41 make any request (including a fee request). It is important, therefore, that you are represented by a qualified individual. 3. Review of the fee authorization: If you or your representative disagrees with the fee authorization, either of you may request a review. Instructions for filing this review are on the fee authorization notice, 4. Payment of fees: If past-due benefrts are payable in your claim, we generally withhold 25 percent of the past-due benefits toward possible attomey fees. If no past- due benefrts are payable or this is an SSI claim, then payment of the fee we have authorized is your responsibility. 5. Penalty for charging an unauthorized fee: If your representative wants to charge and collect from you a fee that is greater than what we had authorized, then he/she is in violation of the law and regulations. Promptly report this to your nearest Social Security office. 18 HCR- ManorCare SKILLED NURSING FACILITY DETERMINATION --A1..,...f.....---.PIll~IeJ........i..,......Ii-I. SNF Name: HCR MatlOfCare-Ca1l1l Hill DATE: -..--1_,_ TO: Name: Debra Johnson RE: Beneficiary Address: 25 Savo Avenue City, state, Zip: Lancaster, PA 17601 Address: 1700 Markel Street Call1l Hill, PA 17011 Jean E. Albriahl Admission Dale: 11127102 Medicare Number (HIC#): 1B7050089A .'lllJ:I~IlW.!.'."-."llI'IClliiJlI..!.'IJIIIr..1IIIJ~ On \ \ _ , ...... reviewed yOU" medical inlamation available at the line of. or prior to adnission, and we believe that the S8lVice(s) f beneficilry nanel needed cId not meet the requi'emenls for coverage under Medcare. The reason is: o You had no 3 day hospifal qualifying stay o You have previously exhausted yOU" 100 Mecicare days coverage and remained at a Medicare skilled level of care o You are not entitled to Medica'e Pa1 A o Your discha-ge fi'om the hospifaUSNF has exceeded 30 days \C- If the resident is waiving MedIcare benefits complete the "Voluntary Waiver of Msdk:are Benefits' Le\ler" .'JIII($JI'J~........~I"~lP)lI...'t~ro'''lI'.''.!.':~lI.JlIl''.!.' C Facility Decision C utilization Review Committee Decision On I I . we reviewed your mecical infonnalion and found Ihatll1e seIVices fum~hed (you) no Ionget qualified as covered u_ _re beginning I I The reason ~: o You have used the full 100 daY" of Medicare coverage allowed under the Medcare program for Skilled Nursing focilily coverage, o Medicare covers medically necesoaIy akilled nursing care needed on a daily bas~, You only needed oral medeatioos. ass~lance with your daily aclivilies and general sl.\lPOflive seIVices. There is no evidence of medea' complicaliono or other medicai reasons Ihal required the skills of a professional nurse or the1apist to safely and effectively carry out your plan of care. Therefore, we believe that your care cannot be covered under Medicare, o Medicare covers medically necesoaIy skilled care needed on a daily bas~, You only needed , Th~ dles not require the skills of a licensed nurse to perfonn the service or 10 manage your care, Since you needed neither skilled nursing nor skilled rehabilitation on a daily basis, we believe your stay is not covered under Medcare, o _re covers medically necessary sk~1ed care needed on a daily basis, You only needed after Since you no longer require skilled nursing and did not need skilled rehabililation on a daily bas~, we believe your stay beginning covered under Medicare. I I I I is not o Medicare covers mOdica11y necessary skiiled care needed on a daily basis, You needed skilled nursing care beginning I I Io observe and evaluale your condition, There ~ no indicaJion of further likelihood of significanl changes in your care plan or of acute changes or complication in your condition, Since you no longer need skilJed nursing Of skilled rehabilitation services on a dai'" basis, we believe your stay after I I is not covered under Medicare, o Medicare covers medeally necessary skiiled care needed on a daily basis, Because of your condtion you needed a skilled nurse from I I through J J to evaluate and manage your care plan, Your condition has improved so the services you need can safely and effectively be given by non skilled persons, Since you no longer require skilled nursing and did not need skilled rehobililalion services on a daily basis, we believe your stay is not covered under Medcare after I I o Medicare covers medical necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time where progressive learning is dernonsllaled, You have learned 10 perform the lasks ordered by your physician by I I bullhe therapjsl continued services, Since you did not need skilled services after that date, we believe your stay is not covered under Medicare beginning I I o Medicare covers medical necessary skilled nursing 0{ rehabilitation selVices you need inclueing teaching and training activities for a reasonable time where progressive learning is demonstrated, You needed only to be reminded to follo,v the physician's instructions, This does not require the skills of a professional nurse or therapist. Therefore, we believe that this selVice is not covered under MeQcare, , 0 Medicare covers medically necessary akiiled nursing or rehabilitation services you need incluang teaching and training activities for a reasonable time where progressive learning is demonstrated. You received teaching and training for a reasonab)e time but demonstrated you were not able, at this lime, to Jeam or make progress to perform the activities ordered by your physician, Therefore, we believe thai skilled services are not covered under Medicare after I I 20 o Medeare COIIe<S daily skilled nUlSing care related to the insertion, sterile ilTigation and replacement of urethral calheter ff the use of the catheter ~ reasonable and necessary for the active treatment of a cisease of the urinary tract or for patients with special me<lcal needs, Skilled lltlWlg ~ not considered mecically necessary when urethral catheters are used only for mere convenience 0( the control of incontinence, Since your catheter was inserted for convenience or the control of your incontinence, We believe that your care is not covered under Medcare, o Medicare oovelS medically necessary skilled rehabililation services, The medical information shows lhallhe only lherapy services you needed beginning I I were repetitive exercises and help with walking, These do nol gene<ally require the skills 0< the sLpelVision of a quafilied therap~t There was no evidence of medical compfJCations which would have required that services be performed by a qualified Iherap~t We believe therapy services are not covered under Medicare after I I o Me<>care COIIe<S me<ically necessary skilled _Iilation services when needed on a daily bas~, The therapy services you received w.,e fo< your overall fitness and general well-be;ng, They did nol require the skills of a qualified therap~l to perform and I 0< 10 sLpelVise the services, Since you did not need skilled nutsing Of skilled rehabilitation services, we believe your stay is not covered under Mecicare, o Medicare COVe<S medicaJly necessaf)' skilled reh,plitation services to es,,",~h a safe and effective program fo maintain yoor functional ,plilies, Th~ program was establ~hed and beginning I I . the therapy sefVices you received w.,e 10 carry out lh~ program, These services do not require the supervision or skills of a therapist and, therefore, we believe that the services are not! would not be covered under Medicare, o Medicare COVe<S medically and necessary skilled care when needed on a daily bas~, The (specify services) you received isfare considered a skiUed service by Medicare, However based on the medical information provided, thislthese services(s) is not/are not considered a specific and lor effective treatment for your condition, Since the services{s} you received was notlwere not reasonable or necessary for the treatment of your condtion, we believe your stay is not covered under Mecicare, o Medicare oovelS medically necessary skilled rehabilitation se!Vices when needed on a daily bas~, The therapy services provided was notlwere nol reasonable in relation to the expected impr<1Jement in your condition, In this case, since you do not need skilled nursing on a daily basis and the therapy services are not considered reasonable and necessary, we believe, your stay is not covered under Medicare, o Medicare covers me<f1Cll11y necessaf)' skilled rehabilitation services when needed on a daily bas~, While you required skilled from I I to I I , the medical information shows that the lherapy services after that time are not reasonable in relation to the expected improvement In your condition. In this case, since you do not need skilled nursing OIl a daily basis and the therapy services are not considered reasonable and necessary, we believe, your stay after I I is not covered under Medicare, o Medicare covers me<ically necessary skilled care when needed on a daily bas~, Allhough (sentice) generally requires the skills of a , the ~equency with which the service ~ given musl be in accordance with accepted standards of medical practice, The service(s) you recejyed ~ noYare not normally needed on a daily bas~, The mOOcal information does not show medical complications which require tile services to be performed on a daily basis. In this case, the services are not considered reasonable and necessary, Since you did not need skilled nursing or skilled rehabilitation on a daily basis, we believe your stay is not covered under Medicare. This decision has not been made by Me<ica'e. It represents a our (or) a the Utilization Review Committee's ju<Vnent that the services you needed did not meet or no longer met Medicare payment reqJirements. A bill v.ill be sent to Me<ica'e for sefVices you received before I I Normally, the bill s,""miffed to MOOcare does not include services provided aft., th~ date, If you want 10 appeal th~ decision. you musl request that the bill sti>mifled to Medicare include the services we detennined 10 be non-cov.,ed, Medicare will notily you of its determination, If you disagree wnh that determination you may file an appeal. C We are placing you in a part of lh~ fac~1y which ~ not approprialely certified by Medicare because yoo do not require a level of care that will qualify as skilled nUlSing care, Nonqualifying services furnished a patienl in a non<:emfied or in appropriately cemfied bed are not payable by Medicare, . IV APDEAL R[G~TS Under a provision of the Medicare law. you do not have 10 pay for non-covered services determined 10 ba custo<ial care 0< no! ,....._ and _ unless you hed reason 10 know the services were non-<:oVered, You are considered 10 know that these services were non- covered effective with the dale of this notice. 'fyoo have questions concerning your liabilify for payment for SM/ices you received prior to the dale of th~ notice, you must requeslthat a bin b e s_ifled 10 Medicare, We regret that this maybe your first notice of lhe I'lOI'K:OVeI'ag of sefVlces under Me<icare, Our efforts 10 contact you earlier in person or by telephone were unsuocessfuJ, Please check one of the boxes below to indcate whether or not you want your bill submitted to Medcare and sign the notice to verify 1"eCef>t. Sincerely yours, Signature of Mninislralive Officer 21 .l&/II--"'"''WII\IItJIImN.....lIll1.''....-..... o A. I do ~t my bill fa' sefVices I c:ootinue to receive to be SlbniU8d 10 the inllm1e<ialy fa' a Maden decisicn. You 1Mll be inlamed when the bill is Slbnitl8d. If you do not receive a famaI Notice of Maden Oetennination witllin 90 days of this rvquest you should contact C MninaSIar FedeIaI C CareFirst (Blue Cross 01 Malytand) C SOIA W. 8" St 1946 Greenspring Dr, Cincinnati. O. Mi203 Timonium, Md. 21093 NIne and Adctess of Interrneclary o a. I stl.m! want my bill fa' sefVices I continue 10 need 10 be Slbnilled 10 !he InlEm1ediery fa' a Medicare decision. I understand thet I do /1C have Mecfcere righlS We bill is not suIlmiU8d. Note; ~nning 0cI0ber 1. 1989. you n not requi'ed to pay fa' sefVices which coold be covered by MedclIre unliIa decision has been made. PJIQ..:fll(a.l!'I~....-........!I_-~lIl.r. o C. This IlCkrlo\I.ledge lhat I received !his notice of non coverage of sefVices under MecIcare on SignellJ8 of Resident or person acting on Residenfs behalf If not si{,1ted by Resident inclcate reIe1ionshJ> to Resident o D. This is to confim lhat you lWlf'8 advised of the non- coverage of !he sefVices under Maden by telephone on I I NIme of person conlacled and relationship to the Resident SignellJ8 of MninisVatiYe Officer cc: 1. Atten<tng Physician 2. Palienfs Financial Record ti..~~..tI.)~.f..I:ll:WlI.):...l.l.I:.:~l(tI.U~.l: 22 I', "0 '.,-""':,;,'" ~,,," Skilled Nursing f.c:IlHu Det8I~aI)8lIO" "!, (Medicare NOtIce oi~'()nc"6fIMgir?'. PUrDose: 1. To notify the patienVresident, in writing as required by federal regulation. that the care and services he/she requires no longer qualifies for Medicare coverage Procedure: Names and Addresses 1. Enter the name of the facility and the facility's address 2. Enter the date the lelter is being drafted (this should be the same date that the notice is given in person or by telephone) to the residenVpatient or the responsible party. 3. Enter the name and address of the person who is to be notified. 4. Enter the name of the residenVpatient in the "RE: Beneficiary" area. S, Enter the date the residenVpatient was admitted for this Medicare covered period. 6. Enter the residenVpatient's Medicare number, Section I. Technically Ineligible Admission This section should only be completed If any of the described conditions apply to the residenVpatient's admission. Ifthis section is appropriate and completed the following sections must also be completed: III. Non-Certified Bed Placement Consent VI. Verification of Receipt of Notice. . Cross out sections II. IV. and V. Section II. Admission or Continued Stay - Skilled CaI8 Denial Reason 1. This section is necessary when a residenVpatient is technically eligible for Medicare coverage but does not meet the care requirements either because there are no skilled care and services or because the care and services are no longer reasonable or necessary; e.g. the patient has stabilized into a safe paltem of chronic or custodial care. 2, Select the one (1) paragraph that best describes the reason the residenVpatient no longer qualifies for skilled Medicare covered care. 3. When notifying a residenVpatient that he or she no longer qualifies for Medicare the following sections of this form must be completed: A. Names and Addresses B. Section" "Admission or Continued Stay - Skilled Care Denial Reason" C. Section III. "Non-Certitied 8ed Placement Consent" (If the resident will be moved to a bed which is not certified by Medicare. D. Section IV. "Appeal Rights" - Signed by the Administrator E. Section V. "Request for MedIcare Intennedlary Revtew" Section III . "Non-Certitied 8ed Placement Consent". This section must be completed if the residenVpatient is to be move to a bed that Is not certified for Medicare. Section IV. . "Appeal Rights". This section should be completed and signed by the Administrator only when the lelter is being given to a resldenVpatient who Is technically qualified for Medicare coverage but oes not meet the care and services requirements for continued Medicare coverage. Section V.. "Request for Medicare Intennediary Review" This section should be completed only hen the lelter is being given to a residenVpatient who is technically qualified for Medicare coverage but does not meet the care and services requirements for continued Medicare coverage. 1, Selection "A" or "8" must be completed. 2. In selection '~" the appropriate Intermediary must be designated 23 3, If the resident/patiertt or responsible party selects "A" the business office must be infolTTled and directed to file a "Demand' or "Patient Insisf' bill". Section VI. "Verlflcatlon of ReceIpt of Notice" - This section should be completed only when the lette is being given to a resident/patient who is technically qualified for Medicare coverage but does not meet the care and services requirements for continued Medicare coverage. 1. If the resident/patient or responsible party receives the notice in person, complete selection "e" and have the person notified sign the receipt section indicating only that they have received this notice. 2. If the resident/patient or responSible party receives the notice by telephone complete selection "0" and send a copy of the notice to the person contacted via a service that provides a signed receipt; e.g., certified mail, courier service, Federal Express, et al. Quick Reference 1. Admission has no three (3) day Qualifying stay or does not have Medicare Part A coverage, complete: A. "Names and AddfflSSes" B. Section I "TechniCIIlly InelIgIble AdmissIon" C. Section III "Non-Cerllfied Bed Placement Consent" D. Section VI. "IIerlflcatlon of Receipt of Notice" 2. Admission or Continued Medicare covered stay is deemed no longer eligible for Medicare complete: A ''Names and AddfflSSes" B. Section I "Technically IneligIble Admission" C Section II "Admission or Continued Stay - Skilled Care Denial Reason o Section III "Non-Certffled Bed Placement Consent" E Section IV, "Appeal RIghts" F Section V. "Request for Medicare Intennedlary Review G Section VI. "IIerlflcatlon of Receipt of Notice" coverage; 3, Letter distribution: A. Original should be filed in the resident/patient's financial record. B. Copy number one (1) should be given to the resident/patiertt or responsible party. C, Copy number two (2) should be given to the attending physician. 24 ATTACHMENT G MEDICARE SECONDARY PAYOR QUESTIONNAIRE 25 !/( H \/dll/l[ (Lilt' MEDICARE SECONDARY PAYOR QUESTIONNAIRE BENEl'I~y,~~JtMA'rI()l'('~~~~I~~~1~~:4--;>j~;t\~'t-~t1;:;;*:?Y{~~t~;~J~V~1~~~~~;;;,.'l'f;:;!;jl-:ir~-:t;; MedicareBeneficillly._ Je."", -I\\\''''iC~vd- PatientA<oount#: Dates ofServioe From: '1"2.1 J <:>2- Througb: Name ofPenco Who Supplied the Informatioo: ,)............ ~\ Io(',~ \tq- ProviderRepn:sentativeName: 'i:::.~ ~ffi-'l.. (' i3 IT::> IUC#: DCN: Relationship to Patient: t\. \ e. c.e.. Input Dale: WO~f~'COMPENSA'I10N" ';iz;:it;,~'; ',' -!:,- 1;<" ;"'i..,,;-;;" ';_:,:~}ts,i2.' 1. Per the pati.... should this illoessI'mjury be covered by. Work... Coolpensalioo claim? HV.., this _ be OIl MSP or condIdonal daIm, DOt Medkare Primary. PLACE V OR N IJ YES orNO 0 What is the claim number?_ What is the original date of iI\iw:y? What is the...... of the Work... Coolpensalioo pbn? What is the address? City? State? Zip? 2, Is the patient covered by the FedenI BIaok Lung program? YES IfVeo, are any of the claim', diaguosjs codes 00 the Deparlment of Labor', uceplllbl. diaguosjs code list? HV.., this....... be OIl MSP or _ dalm,DOt _......,.. BIoek LD2_ DOt .......SNFsbJS YES or NO f' ;~"~:J;,:,{,., ,:-:i_':?}:'~tJ51;~~J~,t\1~;I~:7;;:;!:_;~f~;;:i;\~J~.~:'~,~yr.~$~~:*J,~:}~~~j~~~i-?::::fj Is the patient entitled to _ through the Deparlment of V_ _? If V eo, does the patient want the VA to be cootaoted for authorizatioo of these services? 'i "',iF""",,,,,c,,~~, ,'""; ',"',.W:' I ,;' ,'",",__;-.;";"",f",<"~__"",,~,,.1,\'i-i:5,,:~~!~\,:,,-.;:/-,''/11;;'''\ '/' 'i.:, ,'; l.'__ - ',,' -,,"__' -~ ;, :<",~J'-);\'-- "{_'_~-",':' -", ~~> ,..''__'"" _,'""'" '.",,', ," YESorNO ~ YES or NO , '", '"i":,/,:, "H:'", i<,~'::"",,:',' " , :pnay "I'/i<-" wrn ......vr-i"'~.x'i;:};~;:,:'""-". ,':'1>''''~:'i~'i;;""",':;;!:':' ',', ". 4, AretheservicesCOvercd:::~::=::~ . ,y..AAV~ ........:::0 . ;j:W"""!"'"'' ,"'"",,, IfVeo, what is the name ufthe public healthservioe? What is the address? City? State? Zip? What ia the date uf the services covered by the public health servioe? SNF does DOt pu1Id..'" PHS Sc. Are these services the resuh of an accident? IfYeo, what type of accident was this (For """"'1'1.: Auto, ,lip and fall [pl....listlocatioo of accident). malpradicc, product liability, bomeownen)? Is non-liability insurance available (For """"'1'1.: I'remius medical, auto medical cuvenge, oo-fau1t, bomeownen premises)? lfY c:s, what is the name of the insurance company? ~ What is the address? YES or NO City? What was the date of the accident/injury? Who is listed as the insured? State? Zip? 26 . . .... .',.'" ,<,., ",~;','.'CI'ni."-CO""""""'M+"";.g~~~;w...... '",0"" ",'a,~",'""''''''''''' " .',':',-,"-,:.;'-,....'t.,~'r,;:",~':,~"':i';rr").<~_ .~~",a\..,,,; ^~:"II;..,_~",.,.~m..~~~~,~~....,',l5lf:r.~%.:K.~-;I"''''''!'f;,-;~"j:^; SA Docs the patient feci......... else is rc'pro,ible fur the accidentfmjuty? 'YES or NO ~ " . .. IfYeo, What is the name of the pati....', attomcy or the ...pro,ible party', _ company? What is the address? City? State? Zip? What is the name of the rcspoosible inBurcd party? . EMPLOYER GROUP,BJ:AI.TP:;~ P;'<Y'..', . 6, Is the patient covered by auy employer group hcaIth pbn (EGlIn including the FedenI Employco IIcaI1h Benefits or R~ Polici..? UNo, this q_......la CUIlIpIef<. HYES, CONTINUE. ;.'::;;._'_(;~t,V~~:_,~~!i-'-,.';\%~,~jj5~t:::,~' YE8orNO NO WORKING AGED ,,';':'. <.fi', ...., 7, Is the patient 6S years or older? YES or NO __~ If V eo, is the patient and/or spouse cummly employed by au employer of20 or more employees~" If V eo, is the patient covered by !bat employer group bcalIb pbn (EGHP)? IfYeo, what is the name of the EGHP? What is the address? YES orNO YES or NO /00 City? State? Zip? If the Beneficiary is no 1_ employed, pI.... give. ,OliI_ date ifpoosible: If the spouse is no 1_ employed, pI.... give. retirement date ifpoosible: 8, Is the patient WIder the age 6S? IfYeo, is the patient entitled to Medicare 1IOIcIy due to. disability _tbaD end stage rcnaIw.....? IfYeo, is the patient or &mily member cum:alIy employed by au employer of 100 or more employees? IfYeo, is the patient covered by !bat Iar&e group bcalIb pbn (LGHP)? IfY... what is the name of the LGHP? What is the address? YES YES or NO YES or NO YES orNO City? State? Zip? ,:r__:,.-_~if~)_L:.:-..~,_,;}(' ;,,':J:ND STAGE RENALDW2,.~....~.j(i\;~l;'^";(. ,,' ''''' ,',,",',' ,,,' ,-., ^_,.",,,,,,,,"_,'~J::,,,,,,",",,,,,,/,,,,_ ,;",;'~<:'~;~~ll'J'~;;<}(}'}!l?i':~');'? . YES or NO 9. Is the pati.... covered by any EGHP through. =- or _ employer of any size? N.....ofgroupbcallbplan: Mailing address: City: State: Zip: PoIi<:y#: Relationship to the patient: Name of employer: Mailing address: City: State: Zip: Is the pati.... within the 3_ coordinatioo ofbcocfits periods? What is the lDOOtb/ycar of the first regular dialysis? (MWDDlCCV) Has the patient bad. kidney transplant? Ifyeo, date oftransp1ant: (MMIDDlCCY) No<e: If the patient is within the 30 mootb coordinatioo ofbcocfits period, the GHP should be primary, N..... of policyholder: Group identificatioo #: YES or NO YES or NO "DUAL;ENtrn.E~j','!;!j!ii;l"';' i' 10, Is the patient entitled to Medicare on the basis ofcither ESRD oed age ofESRD oed diBabiIity? Was the patient's initial eutitlcmentto MediC3U'e (incJ.udingRimllftRnN'IUS entitlement) based OIl ESRD? Docs the wodcing aged or MSP disability provisioo apply (ie. the GHP primsry baaed 00 the age or disability entitl...-)? Note, If V.. tolhe.... queodon, lhe GRP........... primary rorlheJOmonlb COB perkNL ".',',;i:';; :;',':'\' YES or NO YES orNO VESorNO No 27 "~~~~t~~.;,,.. .', .l~J Has this palicm -. cooIined to. bo8pilal or slciIled DlUSing facilitywilhio the last 60 days? HV... _plele!be'oIIowIPc __ 'or_ slay: Hoopita! orSNF: I" '3', \ '\\e.c>-.\~SOu..~ Address: ,1'1.>1)' :t." 'I ~"'!'" ,..:' i'"__.' ,-'0 ". ," . . _. ",'_ ..,,\A,n;O;~~'~'~ YESorNO~ AdmisBioo Dale: \\, S. ' 0 Z- DiscIwge Dale: ~~ \\ \z.., 107- ByWbomVcrified 'r,;,,":", .,.{, :~~:!}.-:.;~-:-,,::;:;;;::':' ,:;.~~~~~~~~~tfN:4;\~,~'.:%(i~~:~~~~f~:-';_'~1?;,?-.>~<r'::fG:'/;d;)JJiMMl(j;~1r~:~i;:]:'Y~\~~~l~~~~~ii~J~~~_~~~~;~D~~: 28 ATIACHMENT H-t RESIDENT'S PERSONAL TRUST FUND AGREEMENT - (STANDARD) 30 -- RESIDENT'S PERSONAL TRUST FUND AGREEMENT The undersigned hefeby agree as follows: L The Facility shall furnish the Resident with a written receipt fOf all expenditures and deposits regarding any of the Resident's funds deposited with the Facility, 2, A record of all transactions regarding the Resident's funds shall be maintained by the Facility in accordance with generally accepted accounting principles. 3. The Resident shall have access, at any time upon request, to the above record and shall receive an itemized quarterly statement of hislher account 4. The Facility has a surety bond to guarantee the Resident's funds, 5, All Resident personal funds are kept in separate account(s) from the Facility operating accounts, 6. The Facility may keep Fifty and 00/100 Dollars ($50,00) or less in a non-intefest bearing or petty cash fund fOf the Resident's account Any money in excess of Fifty and 00/100 Dollars ($50,00) will be put in an interest-bearing account. with the interest to be credited to the Resident If the Facility maintains an account with a bank on the resident's behaJf, any service charges assessed by the bank will be deducted from the resident's personaJ tmst fund account. 7, The Resident acknowledges that. upon hislher discharge or death, the balance of hislher account will be promptly released to the private party or public agency required by law. 8, The Resident authorizes the Facility to distribute or return the Resident's money only to the Resident or the Resident's designated representative upon written request. 9. The Facility has no duty to invest the money in the Resident's account to eam income other than interest in a bank checking or similar account, or to accept a deposit which would cause the balance in the Resident's account to exceed applicable limits of federal or state law, 10, If the Resident receives Medicaid benefits, the Facility shall notify the Resident when the amount in hislher account reaches Two Hundred and 00/100 Dollars ($200.00) less than the social security income ("SSf') resource limit for one person and that, if the amount in the account, in addition to the value of the Resident's other nonexempt resources, reaches the SSI resource limit for one person, the Resident may lose eligibility for Medicaid or SSl Date: \\\2..1 \ 0'2- 'f.- \~\.~ ~ ~~ Representative (Sigfiatur9) \::J~ ~ Resident (Signature) Responsible party (Signature) "'^, ";, -\ \ 1M.{': I Resident Name: Albright, Jean E ATTACHMENT B-2 31 -- RESIDENT PERSONAL FUNDS AUTHORIZATION INSTRUCTIONS FOR USE: Required on any resident eligible for Medicaid. Complete the one (1) appropriate section below, as follows: Part A - To be completed when resident requests receipt of the personal portion of their resource check or personal fund. Part B - To be completed when the resident's responsible party requests receipt of the resource check or personal fund, Part C - To be completed when the resident requests that the facility become the custodian of the personal portion of the resource check or personal funds, Please ensure that in all cases, all signature approvals are obtained as indicated on the lower part of this fonn. PART A Date: I, Albrillht. Jean E, Patient No. 1310 as a resident of , request to receive monthly the personal portion of my resource check or personal funds in the amount of $ . By receipt of this money I hold hannless for any loss or further responsibility of this money, PART B Date: As the responsible party for Albrillht. Jean E, Resident No, 1310 at I am requesting to receive monthly, the personal portion of their resource check in the amount of $ responsible party, I realize a legal obligation to use these funds for the benefit of the patient and hold . ~ hannless for any further responsibility for this money. RULES AND REGULATIONS: 1. The facility will not loan funds to a resident whose balance falls to zero.2. The resident's signature is required for all withdrawals. If a resident is unable to sign, two witnesses who do not receive or disperse resident funds, petty cash or checks may sign for a resident. PART C Date: I, Albrillht. Jean E, Patient No. 1310 as a resident of designate on account. to be custodian of the personal portion of my resource check, or private funds depositec Witness (Required parts A, B, and C) Witness & Non-Employee (Required parts A, B, and C) Resident Signature (Required parts A, B, and C) Responsible Party (Required parts A, B, or C, as appropriate) 1700 Market Street Camo Hill. PA 17011 Address (Required Parts A, Band C ) Administrator Approval I Resident Name: Albright, Jean E 33 / ATTACHMENT I CENTER SUPPLEMENT . BEDHOLD POLICY . SOCIAL SERVICE AGENCIES AND ADVOCACY GROUPS . OMBUDSMAN . INFORMATION ON AGENCIES, GROUPS AND GOVERNMENTAL AGENCIESIUNITS . MEDICAL DIRECTORS/PHYSICIANS . FILING A COMPLIANT FOR ABUSE, NEGLECT, MISTREATMENT OR MISAPPROPRIATION /' ATTACHMENT J RESIDENT HANDBOOK I ATTACHMENT K RESIDENT/PATIENT RIGHTS ! ATTACHMENT L MEDICARE/MEDICAID INFORMATION / ATTACHMENT M-l REFUSAL OF LIFE-SUSTAINING TREATMENT POLICY /ATTACHMENT M-2 ADVANCED DIRECTIVES STATUS WORKSHEET 34 HeR MANOR CARE REFUSAL OF LIFE-SUSTAINING TREATMENT HCR Manor Care Centers are dedicated to supporting the resident to attain or maintain his or her highest level or physical, mental, and psychosocial well-being, in accordance with the resident's personal assessment, his or her individualized Plan of Care, and the resident's wishes as to medical treatment. The resident's condition, however, may lead him or her to desire to limit the treatment provided by the Center. In such event, HCR Manor Care Centers will honor the fequests of the resident to refuse life-prolonging treatment, provided that such refusals are done in accordance with HCR Manor Care's policies, These policies are designed to protect each resident's rights by following applicable state law governing who can legally consent to refuse treatment and requiring that the medical record reflect that any other applicable legal requirements have been satisfied. HCRMANORCAREPOLICY HeR MANOR CARE'S policy is to provide all treaJment which is medically necessary to sustain the resident's life, unless a valid order to refuse such treatment is entered in the resident's medical record by his or her attending physician, in accordance with HCR Manor Care's Limited Treatment Policy or Policy on "Do Not Resuscitate Orders" ("DNR''), whichever may be applicable. Understanding Limited Treatment HCR Manor Care follows applicable federal and state laws governing the rights of a resident, whether competent or incompetent, to refuse unwanted medical treatment. An incompetent resident can direct care through an "advance directive" under applicable state law. A growing number of states also permit family members to act as "surrogate decision makers" in the absence of an advance directive. Duly empowered legal guardians might also be permitted to refuse life-sustaining treatment under applicable state law. Because the laws of each state are unique, HCR Manor Care has a Limited Treatment Policy for each state, A summary of this State's laws on advance directives and surrogate decision making is contained in the admissions packet. The Limited Treatment Policy imposes procedural requirements for refusing life-sustaining medical treatment such as mechanical breathing, kidney dialysis, chemotherapy, blood tfansfusions, and artificial nutrition and hydration supplied intravenously or through gastric or nasogastric feeding tubes, Antibiotics might be refused if they are not needed to alleviate pain and the safety of others in the Center is not threatened. Whether or not to refuse treatment is a decision to be made by the resident and/or legal representative based upon the advice of the attending physician, HCR ManOf Care recommends that the resident's decisions on the various treatment options be stated with as much specificity as possible. It is also recommended that the resident execute advance directives and, if a durable 35 power of attorney for health care is executed, that the resident discuss his or her wishes in detail with the designated person, Understanding CPR CPR is emergency medical procedure used in an attempt to restore circulation and respiration, which have ceased. The cessation of circulation and respiration is referred to as a cardiopulmonary arrest. It may take several minutes from the onset of a cardiopulmonary arrest to the point when the condition becomes irreversible. This time interval may represent a "window of opportunity" when CPR may be effective in restoring circulation and respiration, CPR consists of both basic and advanced life support procedures. Basic CPR involves rescue breathing and chest compressions, Rescue breathing is performed mouth-to-mouth or by using a special mask and bag. Chest compression, or external cardiac massage, is the compression of the chest at the lower part of the sternum with one's hands, using the weight of one's body for pressure, It is done to force the circulation of blood through vital organs. According to reputable industry studies, CPR has significant limitations. It may fail to restore circulation or respiration, Even if CPR results in the avoidance of death by the traditional definition, it may be too late to prevent brsin damage. Additionally, circulation and respiration may be restored in time to preserve brain function, but administration of CPR may fracture ribs, lacerate organs, or result in other injuries. The administration of CPR is most likely to be successful when the resident is relatively young and does not have a debilitating condition, Center personnel will perform Basic CPR if a resident has a cardiopulmonary arrest unless a valid physician order has been entered in the resident's medical chart or CPR would be unsuccessful in restoring cardiac and respiratory function, Advanced CPR involves higher technology and will be administered only by paramedics called to the Center to administer IlUch procedures and to transport the resident to the hospitaL 36 LIMITED TREATMENT POLICY - PENNSYLVANIA HCR Manor Care's policy is that all residents will be provided health care unless the attending physician enters a contrary order in the resident's medical record. The Center will act to maintain human life in accordance with accepted standards of ethical practice. Health care will be withheld only in accordance with the procedures setforth in HCR Manor Care's Limited Treatment Policy for Pennsylvania, which is summarized below. Competent Resident A competent resident can refuse medical treatment, including artificial nutrition and hydration, at any time, The attending physician must, however, record complete infonnation in the resident's medical record to demonstrate that the decision to refuse treatment was made on the basis ofinfonned consent, Incompetent Resident Pennsylvania law permits decisions to be made on behalf of an incompetent resident in several ways, 1. Declaration. If when competent, the resident has executed a living will (known in Pennsylvania as a "Declaration") in accordance with Pennsylvania law, then life-sustaining treatment can be withheld in accordance with the resident's instructions set forth in the declaration provided that the following requirements are met: a, The attending physician determines that the resident is incompetent; b, The procedure of treatment proposed to be withheld is consistent with the specific instructions, if any, of the resident set forth in the Declaration; c, The attending physician certifies in the medical record that the resident is either in a terminal condition or is in a state of permanent unconsciousness; and d, The attending physician arranges for the physical examination and confirmation of the terminal condition or state of permanent unconsciousness by a second physician. If the resident in his or her Declaration designated a surrogate to make decisions under these circumstances, then the consent of such surrogate will also be required, Artificial nutrition and hydration can only be withheld if all of the foregoing requirements have been met and the Declaration specifically provides for the withholding of artificial nutrition and hydration, e. Durable Power of Attorney and no Declaration. The Pennsylvania Durable Power of Attorney Act authorizes consent for medical treatment, but does not specifically authorize the withholding oflife-sustaining treatment. Therefore,' unless there is a court order providing otherwise, HCR Manor Care may not honor a durable power of attorney for health care. Any such document will be forwarded to the Legal Department for review, 37 2. Legal Guardian. Pennsylvania law may permit a legal guardian to authorize the withholding of Iife- sustaining treatment, The scope of the guardian's authority will be verified by the court documents which appointed the guardian, 3, Close Family Member and Persistent Vegetative State. If the resident did not executive a valid Declaration or Durable Power of Attorney, or if the resident does not have a legal guardian with authority to refuse life-sustaining treatment, then Pennsylvania law permits a family member who is sufficiently close to the resident to render a judgment on his or her behalf to refuse life-sustaining treatment for a resident who is determined by two qualified physicians to be in a "persistent vegetative state," provided that there is no dispute among family members, Additionally the attending physician must record complete infonnation in the resident's medical record to demonstrate that the decision of the legal representative to refuse treatment was made on the basis of informed consent and that all other federal and state law requirements have been satisfied, 38 DO NOT RESUSCITATE POLICY CPR will be initiated without a sp<<ijic physician's order or appropriate "Do Not Resuscitate Identification" when cardiac or respiratory fl11'eSt is recognized A sp<<ijic instruction is n<<essf11'y if CPR is not to be initiated, except in instances in which CPR will be unsuccessful in restoring cardiac and respiratory function. A valid DNR Order precludes the otherwise automatic initiation of CPR. A Do Not Resuscitate Order can be entered only by the resident's attending physician, after consent has been obtained from the legal decision maker and the required documentation has been inserted into the resident's medical record, in accofdance with HCR Manor Care's Do Not Resuscitate policy, The legal decision maker for a competent resident is, of course, the resident. The medical record must reflect that an infooned decision was made by the competent resident after discussion of all aspects of CPR with the attending physician. For an incompetent resident, entry of a Do Not Resuscitate order is appropriate only when the resident has either of the following physical conditions: (I) death is expected because of a tenninal condition, or (2) a condition exists in which CPR would not be expected to render substantial improvement in the ultimate outcome, Additionally, the legally recognized surrogate decision maker must consent in writing to the entry of the Do Not Resuscitate order, and the medical record must reflect that such person made an infonned decision after discussion of all aspects of the order with the attending physician. The legally recognized surrogate decision makers for the purposes of the Do Not Resuscitate policy are the same as for a resident have no advance directives under the Limited Treatment Policy - Pennsylvania, described above, * * * The above discussion will assist you in understanding HCR Manor Care's policies as to refusal of life-sustaining treatment. The Admissions Director will also explain HCR Manor Care's policies to the resident and the resident's legal representative at admission, and other staff members are available to answer any questions that may arise during the resident's stay at our Center. Copies of the full policies are available upon request. 39 ** ~0'38~d ~101 ** HCR MANOR CARE ACKNOWLEDGMENT OF RECEIPT OF HCR MANOR CARE POLICD.:S ON LIMITED TREATMENT PRACI1CES AND DO NOT RESUSCITATE ORDERS The Resident and/or Legal Representative hereby certify that he/she has received a copy ofHCR Manor Care's Policies on Limited Treatment Practices and Do Not Resuscitate Orders as part of the admissions packet. The Resident and/or Legal Representative fi.uther certify that he/she has read and understood the policies, that he/she has had an opportuDity to ask questions about the policies, and that hislher questions have been answered to hislher satisfilction. The Residem and/or Legal Representative understand that limited treatment or "No CPR" orders can only be entered by the Resident's attending physician when other conditions of the policy have heen satisfied. The Resident and/or Legal Representative understand that, prior to the entJy ofvaJid limited treatment or No CPR orders by the attending physician, it is the policy of HeR Manor Care to provide all medically necessary health care services, includin& when medically indicated, CPR The Resident and/or Legal Representative therefore acknowledge hisIher responsibility to discuss the Resident's desires for limited treatment or No CPR orders with bisIher attending physiclan. SignatUre of Resident, if able to make medical decisions: Date: Signature of Resident's Legal Representative, if Resident is unable to make medical decisions: Date: 1\12.1/02.. k~ ~ ~ lL- _ ~-^"- s.~tf\er Center Representative Date: "/~,}O"2- 40 G0/~0'd SS~S6V~ 01 68.~ ~E~ ~.~ llIH dW~J-3~~J ~ON~W ~d .e:.. vee~ 0G d35 Advanced Directive Status Worksheet (To Be Used in Conjunction with HCR Manor Care Limited Treatment Policy) Admission Date: 11/27/02 O,JVAdmission ~ipt ofHCR Manor Care "Refusal of Life-Sustaining Treatment" Handout _ Signed Acknowledgement of Receipt of HCR Manor Care Policy on Limited Treatment ~I'ractices and no cardiopulmomuy resnscitation orders _ Provided with "State's Advanced Directive Forms - if desired (See Advanced Directives*) Responsible Party Name & Phone # . Resident (Competent) . Legal Guardian (Resident Incompetent) (Indicate if Gnardian is over person, property, or both) Dnrable POA/Health Care Proxy _ Legal RepreseutativcJFamily None of the above Advanced Directives. Living Wil1IDeclaration _ Durnble Power-of-Attomey for Health Care Other Note: If out of state advanced directive, an old advanced directive, if there are missing dates, signatures, or an improperly witness advanced directive, contact the Legal Department for assistance, No CPR/DNR Orders _ Physician's Order (Original order must be handwritten on physician's order sheet and placed on the chart~mputer printout accepted thereafter.) _ Physician Documentation of Informed Consent in Progress Note _ Compliance with HCR Manor Care Policy in Section 3 of the Limited Treatment Policy Manual _ HCR Manor Care Release of Liability for the Limited Treatment Order (**Note) Limited Treatment Physician's Order (See above under "Physician's Order") Physician Documentation of Informed Consent in Progress Note Compliance with HCR Manor Care Policy in Section 2 of the Limited Treatment , Policy Manual HCR Manor Care Release of Liability for the Limited Treatment Order (**Note) Organ Donor Receipt of Information Related to Organ Donation Organ Donation Desired Date Received IIl71/lS Z. Signature W) .. Note: Update advanced directive orders 00 a moothIy basis. Verify that the resident or legal represeutative COIJtinues to want the ordered treatment withhcld/withdra_ or DNR status, For residents with no orden for DNR or Limited Tn:almcflt, verily periodically and with. significant chango in status or tcnninaI diagnosi~ whether they dcaire . No CPRlDNR or Limited Treatment Order. ""Nute: AtIcr lhc physiciau has obtained informed COIISenI, obtain the si@ll&lUreoftheresident or legol rcpresentative(,) 00 lhc HeR Manor Care Release ofUability form unless the situation makes it impossible to do so. Try faxing. mailing or reading fonD (on lhc phone with witnessing) to lhc legalr<prcsentativc in each child sign the ..I.... form. I Resident Name: Albright, Jean E Medical Record #: 1310 41 /I( R l/ullol' ( UI'(' PRIVACY ACT STATEMENT-HEALTH CARE RECORDS THIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PRIVACY ACT OF 1974. THIS FORM IS NOT A CONSENT TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU. L AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN) Sections 1819(t), 1919(t), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act, Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status, As of June 22, 1998 all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronical1y transmit this information to the State, The State is then required to transmit the data to the federal Central Office Minimum Data Set (MDS) repository of the Health Care Financing Administration. These data are protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records, 2, PRINCIPAL PURPOSES FOR wmCH INFORMATION IS INTENDED TO BE USED The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes that participate in Medicare or Medicaid, Submission of MDS information may also be necessary for the nursing homes to receive reimbursement for Medicare services. 3, ROUTINE USES The primary use of this information is to aid in the administration of the survey and certification of MedicarelMedicaid long term care facilities and to improve the effectiveness and quality of care given in those facilities, This system will also support regulatory, reimbursement, policy, and research functions, This system will collect the minimum amount of personal data needed to accomplish its stated purpose, 43 The information collected will be entered into the Long Term Care Minimum Data Set (LTC MDS) system of records, System No, 09-70-1516. Information from this system may be disclosed, under specific circumstances, to: (1) a congressional office from the record of an individual in response to an inquiry from the congressional made at the request of that individual; (2) the Federal Bureau of Census; (3) the Federal Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease of disability, or the restoration of health; (5) contractors working for HCFA to carry out MedicareIMedicaid functions, collating or analyZing data, or to detect fraud or abuse; (6) an agency of a State government for purposes of determining, evaluating and/or assessing overall or aggregate cost, effectiveness, and/or quality of health care services provided in the State; (7) another Federal agency to fulfill a requirement of a Federal statute that implements a health benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII functions, (9) another entity that makes payment for or oversees administration of health care services for preventing fraud or abuse under specific conditions. 4, WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION For nursing home residents residing in a certified MedicareIMedicaid nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of care given in certified facilities and to assess the appropriateness of provided services. If a nursing home does not submit the required data it cannot be reimbursed for any MedicarelMedicaid services, 44 pr/n'.--'........"lIn",.,"IIII1_ )fS:M We are pleased that you will allow Ancillary Services Management, Inc. ("ASM") to serve your Medicare Part B sUPI,7yiieiiils. JfSM rs~a -national Medicare Part B provider and has an agreement with this facility to provide certain medical products for eligible nursing home residents. Some of the products ASM supplies include nutritional supplies for tube feeding, foley catheters for urological patients, surgical dressing supplies, as well as ostomy and tracheostomy supplies for those patients who require them. The Health Care Financing Administration, which is the governmental agency responsible for the Medicare program, requires providers like us to obtain authorization to supply, bill and receive payments on behaff of the beneficiary from the beneficiary and/or responsible party. In the event you need the supplies noted above, we can supply and bill Medicare Part B on your behalf. Please sign and date below, authorizing ASM to bill Medicare Part B on behaff of the beneficiary. Once again, thank you for your business. ff you have any questions, please feel free to contact ASM at (419) 252-6000. Sincerely, Frank A. Jannazo Director of Operations ................................................................................................. SELEcnON OF ASM Patient Name: Albriaht Jean Last First Social Security #: 187-05-0089 E Middle Facility: HCR ManorCare-CamD Hill The resident and/or legal representative hereby selects ASM to provide Medicare Part B supplies ordered by the resident's attending physician. The resident and/or legal representative hereby request that Medicare benefits be paid directly to ASM for any medical supplies provided to the resident which are covered under Medicare Part B and hereby authorize ASM to bill and collect for such medical supplies directly from Medicare or other third party payor. I further authorize any holder of medical information about me to release to the third party payor(s) and its agents any information needed to determine these benef"tts. Date Resident Signature ^ ~~\.," ~ ~c~ Signature of Lega/lkep~entatlve "I L' I DC. Date 48 ATTESTATION OF ADMISSION AGREEMENT AND ATTACHMENT I ~w"" "S~ff\ ~ , on behalf of the Center HCR ManorCare-Camp Hill Name Center hereby certify, as indicated by my initials set forth below, that I have provided the Resident and/or Legal Repfesentative of Albright. Jean E with the Resident Name Admission Agreement and each of the attachments listed below, I also acknowledge that I have gone over each of the attachments with the Resident and/or Legal Representative, that the Resident and/or Legal Representative have had the opportunity to ask questions and have had all of their questions answered satisfactorily. The Resident and/or Legal Repfesentative have signed each of the required documents in my presence indicating receipt and understanding, ~. Authorization for Release or Review of Medical Information. See Attachment C. :; ):>; Authorization for Payment of Benefits, See Attachment D, ,c, Social Security Administration Appointment. See Attachment E. ~d. SNF Medicare Determination Notice, See Attachment F. / -- e. Medicare Secondary Payor Questionnaire, See Attachment G, ~f At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds, A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachment H-I and H-2. /' R, The Center's policy and procedure on bedholds, election of bedholds and readmission, See Attachment 1. ~h. Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). Name, address and phone number of Ombudsman. See Attachment I (Center Supplement), The location in the Center where the names, addresses and telephone numbefs of state cllent advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy netwofk and the Medicaid fraud control unit. See Attachment I (Center / Supplement). _ k The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center, See Attachment I (Center / Supplement). _I. Procedufes, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property, See Attachment I (Center / Supplement), ---T-m, The Resident Handbook See Attachment J _n, ResidentlPatient Rights, See Attachment K. ~o, MedicarelMedicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive fefunds fOf previous payments, See Attachment L. 1, Copy of Medicare Card for file, /< I. - /. 1, 49 2. Copy of Medicaid Card for file, p, Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct hislher medical treatment. See Attachment M-l and M-2, /q, Privacy Act Notification. See Attachment N, _r. Inventory sheet and/or policy of personal items. See Attachment O. ./ s, ASM Form. See Attachment p, _t. Copy of Social Security Card for file, u, Copy of all insurance cards for file, _v. Copy of Prescription Card for file. Note: please copy both sides of card. .-w.Copy of Living Will for file. ../' x, Copy of Health Care and Financial Power of Attorney for file, v. Copy of Guardianship or Health Care Surrogate papers for file, ~: Complete Admitting and Discharge Record (Face Sheet). ./ aa, Verification of Medicare Coverage through mQA. bb. See Attachment Q, cc. See Attachment R dd. See Attachment S. ee, See Attachment T, _ff See Attachment V. The Admission process for the above named Resident was completed on the date(s) set forth below, ~""'^- s,-\-oe.ffi-e..- Name lq"l- -<102. Date 50 --- .~.,,'" FR MRNOR CRRE 717 737 7389 TO 6655251 P.0l/04 HCR.ManorCare APPLICATION FOR RESIDENCY To apply for admissiOll to our Nursing Center, please complete Ihe following questionnaire, sign, and ~tum it to tbe Admis.~iolls Office. This application will bec:ome a part of tbe NAdmissioD Agreement" and should be completed in itJ entirety. All information will be held in confidence. Tbe complete medical history and physical examination resulU will be recorded 011 8nothu document. Date: 11-1 '1-0)- Name of Prospective ResidenUPatient: ~ \ €A 10 Date of Birth: 05'- Q3- /6 Address: 8'.;lD /-./ S (,lu ~ Rcl. APT lice:, (Iiud) CAmfl Ui If PA 170/1 Marital Status: Married Widowed If Married or Widowed, Name of Spouse Social Security No: \ ~ '\ - () So - a~"t,~ HMOllnsurance: Provider \ C. \-\ ~ ID No: l::lc::,"\O "'\" ~ Group No: Insurance is: Primary Secondary Other Insurance: Provider ID No: Group No: Insurance is: Primary Secondary h. Alb/?'dHT Sex:F~M_ Telephone No.: 7} 1- 7fc,d-ij 197 Single ~ Medicare No: Policy No. Co-insurance Policy No. Co-insurance Name of Inquirer: 'Dee.OI!.fH! J. 00 i+bJSutJ Address: C}.O S'Auo .4ve.. (line 2) /..A....Jc.J>.S-/e,e, P,4 17 b 0 I Other persons to cQntact in case of emergency: Name: Address: (line 2) Relationship: 1\J I eC.~ Telephone No.: 1/7-SI./t-}Cj'l'1 Other Phone No,: 7/7-tr,~<j-o.irOO Relationship: Telephone No: Other Phone No,: How did you hear about Personal Referral Hospital H-€.A If A So 11.;1-1., Physician Other Professional MailingIBrocbure Other Nursing Ctr. rY1 hIVo JZ.. C4~ '€.- Nursing Center? . NewspaperlMagazine ~M~ TelevisionIRadio Yellow Pages Health Dept. Seminar/Event Assisted Living Ctr. Have you visited any other Nursing Centers or Assisted Living facilities? If yes. which ones? ;00 {)(IiIBI7 He I NDV-13-2002 11:53 717 737 7389 99% NOU 13 2002 12:02 FR MRNOR CRRE 717 737 7389 TO 6655251 P.02/04 PERSONALIMEDICAL DATA Mother's Maiden Name: Father's Nllme: (AIAJk>1L G;,be..2.So,v Place of Birth: City /-ANCA-s-k>.e... County t.-A-NcA-s-k..L ,State P A- Church Preference (Optional): Preferred Ambulance Company (Optional): Name City Diagnosis: Cun-ent Primary Physician: Dt<.. PeJ:J..NA Physician to follow at Facility: Telephone No.: Telephone No.: Tell us about the ResidentlPatient: (please check all that apply) _Mentally alert _Ambulatory _Confined to bcd ~~Slightly forgetful \to!.sWalks with assistance bl2Eats without assistance (fe.J6'Q) _Confused _Continent ~e.s: Requires assistance with Ill. ~ IlS Incontinent eating Admission desired on: Resident/patient currently llt: ~ 1-Ie.4H-J, SOi,.(..:H" If hospital: Date admitted Admitted from Where has the resident/patient lived in the last 60 days?: H-o Y\'1 e - '+old bPIR;-r AosP <L- l-I-e4/+h SOlA.+k FINANCIAL INFORMATION The facility requires tbat a source af payment by identified to pay for tbe ResidClltlPatient's care. A penooa, other than the resident, may wish to.be financially responsible for the cost of the care ("guarantor"). The facility does nol require a Mguarantor". Name of the "Guarantor": Address: Telephone No.: Work No.: Other No.: (This person(s) must also complete the "Guarantor" information and sign the application.) Has a trust fund been established for the ResidentlParient?: Yes No Has a Power of Attorney been conferred on the person(s) to be financially responsible, or on the person(s) who will act on behalf of the resident ("Responsible Party")?: _Yes _No If yes, please provide a copy. Has a legal guardian been llppointed by a court? _Yes _No If yes, please provide a copy. Has a Burial Trust been established?: _Yes _No If yes, with whom?: If no, who is lhe preferred funeral service for the Resident/Patient's family?: 2 NOU-13-2002 11:53 717 737 7389 98% P.02 NOV 13 2002 12:03 FR MqNOR CqRE 717 737 7383 TO 5555251 P.03/04 To process your application, tbe following infonnation is required, The infonnalion supplied is confidential and allows us to assist you in your long-tenn planaing. The fioancial data should be that of fhe ResidenrlPatient and or the Guaranlor. All income and amouats listed, whetber listed uader tbe Resident or Guaramor eolumn, must eitber be owned by the Resident or in fact be anilable to tbe Resideot to pay for the Resident's 51ay at the racility. Your cooperatioa is appreciated in order to e>:pedire admission. Please Dote that il is not mandated thaI a ResideDt bave a Guaraalor, only that a source of payment be identified. Tbus, any person who agrees 10 be a Guar2ntor is doing so voluntarily. ASSETS: Cash Checking Savings Money-Market Certificates of Deposit Securities (StockslBonds) Trust Annuities (if not yet paying IRA montbly) MONTHLY INCOME: Salary $ Social Security Pensions/Annuities (if not abo~e) IRA (if not above) InteresUDividend Income Rental Income Trust Investments/Other Long-Term Care Insurance RESIDENT GUARANTOR (if any) S $ t \ t)1';:;(\.1) a \\~\\<L ~CI<;\~ \\ a ~e....- '" 1\ t\<L ' ~Q~ \\0 ~<2-- $ \ \',at,. ~~ 'i\ () ~~ \(\ C\ I\<L- '<\ t\ t\ (' \'\.(',1\(' _ '1\ 0 (\Q..- 'l\ 0 I\C!.- '<\OI'\C-- NA REAL ESTATE: (descriptioilllocation) Property: r.J a IV e... Name on Deedtritle Property: tV a rd e Name on Deedtritle OTHER ASSETS: Cash Value Life Insurance Vested Pension Benefits Business Interests Automobiles Other Total Assets: NOV-13-2002 11:53 717 737 7389 ~Cl~ '" (> <<:' - '" () "e. __ \\\:iN:~ J 98% P.03 l ;_t:c ~ .. , , - __,~~ ~~ MANOR CARE LIABILITIES: Home Mortgage Credit Cards/Charge Accounts Loans Other Debts Tans Owed Total Liabilities: NET WORTH: (assets * liabilities) 717 737 7389 TO 6655251 P.04/04 s RESIDENT \(\Cl:\~ GUARANTOR $ \(\ CI <;'.Q.......,. 'v\ C> \\~ IJ\C>~ $ $ PLEASE SIGN BELOW: I hereby warrant and represent Ihat the information provided il aa:urate aud compltte. I ulldentand th:ltthe lIursing facility will rely upollthe attllracy and compltUllC5s of the allo,"" financial illfonnalioll ill making aa admission decisiolL I also ulldema.ad lIIar if:lllY of tbe ill formation is 1I0t accurate or nol complete. tbe Facility ..ill ban detrimCfttally relied upon the above fillaJIdaJ informalioll and will suffer fin2Jl<:ialloS! and harm. The a.uets lmed are in fa.c:t aVlIJ'able 10 Ihe Resident to pay for the Residt.llt's care. \5f J\ f-I ~4,S Reside"t's or Respo....ible Party's Signature Guarantor's Signalure Reviewed by: ?!!72~. iil;3~S~- Admioi.'trator's Sign I ttJ HfJ NOU-13-2002 11:54 717 737 7389 12- lo -0"2.- D:m Date /1./ '!UL Date 1c9)~2 Date 4 96% ** TOTAL PAGE, 04 ** P.B4 ":Ar ~ ~ '0\ ~ v, 0 - ~ ~ ~ w ~ t;;' --.0 ~ \j::) " " (' ....'_.'~;~- <' G ;'~, '--,,') .,.---- -- G:\Users\ajo\RCG\LitigationVonson, Deborah POs.""'!Xi:l0/20/04 Gary G. Krafft, Esquire Attorney J.D. No.: 19351 Russell, Krafft & Gruber, LLP Hempfield Center, Suite 300 930 Red Rose Court Lancaster, PA 17601 Telephone No.: (717) 293-9293 Facsimile No.: (717) 293-5130 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC. Plaintiff Docket No. 2004-4776 v, DEBORAH J. JOHNSON a/k/a DEBRA J. JOHNSON Defendant PRELIMINARY OBJECTIONS OF DEFENDANT. DEBORAH J. JOHNSON PA.R.C.P. 1028(a)(3) - INSUFFICIENT SPECIFICITY - COUNT I I. On or about September 22, 2004, Plaintiff filed a two (2) count Complaint in the above-captioned matter, sounding in Breach of Contract and "Money Had and Received." 2. Defendant accepted service of said Complaint on October I, 2004, at the Lancaster County Sheriffs Office. 3, Count I of Plaintiffs' Complaint sounds in Breach of Contract. 4. Said Count I demands damages in the amount of $ 17,395.28, plus late fees in the amount of$ 2,091.08. No, 2004-4776 5. Plaintifffails to aver how said damages in the amount of$ 17,395.28 are calculated and as such lacks specificity in its pleading. WHEREFORE, Defendant Deborah 1. Johnson respectfully requests this Court order Plaintiff to more specifically plead Count I of its Complaint within twenty (20) days. PARC.P. 1028(a)(3) - INSUFFICIENT SPECIFICITY - COUNT II 6. Paragraphs 1 through 5 are incorporated herein as if set forth in full. 7. Count II of Plaintiffs Complaint sounds in "Money Had and Received." 8. In Count II of its Complaint, Plaintiff has failed to plead facts which would establish any cognizable cause of action in the Commonwealth of Pennsylvania. WHEREFORE, Defendant Deborah J. Johnson respectfully requests this Court order Plaintiff to more specifically plead Count II of its Complaint within twenty (20) days. PA.R.CP. 1028(a)(4) - DEMURRER-LEGAL INSUFFICIENCY - COUNT I 9. Paragraphs 1 through 8 are incorporated herein as if set forth in full. 10. Count I of Plaintiffs' Complaint sounds in Breach of Contract. 11. Said Count I demands damages in the amount of $ 17,395.28, plus late fees in the amount of$ 2,091.08. 12. Plaintiff fails to aver at least one (1) of the three (3) required elements to establish a prima facie case of Breach of Contract. 13. Specifically, Plaintiff fails to aver the resultant damages allegedly caused by Defendant's alleged breach of contract and the method of calculation of the same. 2 No, 2004-4776 14, The Complaint is further deficient in that the Admission Agreement attached to the Complaint as Exhibit "B" fails to recite any consideration for any alleged duties of Defendant, nor is the Admission Agreement legally binding upon Defendant pursuant to the Uniform Written Obligation Act, 33 P.S. 96. IS, The Complaint fails to recite any consideration to Defendant for her alleged duty under the Admission Agreement. 16. Plaintiff s Complaint fails on its face to assert a cause of action as a matter of law as to Count I - Breach of Contract. 17. Plaintiff s Complaint is clearly insufficient to establish a right to relief as to Count I - Breach of Contract. WHEREFORE, Defendant Deborah 1. Johnson respectfully requests that Count I of Plaintiffs Complaint be dismissed, with prejudice, PA.R.C.P. 102S(a)(S) - FAILURE TO JOIN A NECESSARY PARTY IS. Paragraphs I through 17 are incorporated herein as if set forth in full. 19. Plaintiff s Complaint purports to initiate litigation against Deborah J. Johnson in her capacity as "Legal Representative" for Jean E. Albright with causes of action sounding in Breach of Contract and "Money Had and Received," 20. Said Complaint fails to join the Estate of Jean E. Albright as a necessary party to the contract action. 21. The contract at issue concerns a personal service contract for the nursing care and maintenance of Jean E. Albright, now deceased, 3 No, 2004,4776 22. Said contract was counter-signed by Deborah J. Johnson as "Legal Representative, signing on behalf of Resident." See Exhibit "8" as attached to Plaintiffs Complaint, at page 9. 23. The Estate of Jean E. Albright is an indispensable and necessary party to the instant action. WHEREFORE, Defendant Deborah 1. Johnson respectfully requests that Plaintiffs Complaint be dismissed, with prejudice. 86 Gary G. Krafft Atty. ID No. 19351 Hempfield Center, Suite 300 930 Red Rose Court Lancaster, PA 17601 Telephone: (717) 293-9293 Facsimile: (717) 293-5130 4 No, 2004-4776 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC. Plaintiff Docket No. 2004-4776 v. DEBORAH J. JOHNSON aIkIa DEBRA 1. JOHNSON Defendant CERTIFICATE OF SERVICE I hereby certify that on the date set forth below, I served upon the following person(s) and in the manner indicated below, a true and correct copy of Defendant' s Preliminary Objections in the above captioned matter. Service via First Class Mail and addressed as follows: David A. Baric, Esquire O'BRIEN, BARIC & SCHERER 19 West South Street Carlisle, PA 18013 Dated: 1"\ ;)U\ Di RUSSELL, KRAFFT & GRUBER, L.L.P. BY~~) Gary G. Krafft Atty.IDNo.19351 Hempfield Center, Suite 300 930 Red Rose Court Lancaster" P A 1760 I Telephone: (717) 293-9293 Facsimile: (717) 293-5130 No, 2004.4776 , SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2004-04776 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANORCARE INC VS JOHNSON DEBORAH J AKA DEBRA J R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: JOHNSON DEBORAH J AKA DEBRA J JOHNSON but was unable to locate Her in his bailiwick. He therefore deputized the sheriff of LANCASTER County, Pennsylvania, to serve the within COMPLAINT & NOTICE On October 15th , 2004 , this office was in receipt of the attached return from LANCASTER Sheriff's Costs: Docketing Out of County Surcharge Dep Lancaster Co 18.00 9.00 10.00 38.38 .00 75.38 10/15/2004 OBRIEN BARIC S . ___'~'7 o answers: C"" ' ///:< ",// R. z:~?~ Sheriff of Cumberland County SCHERER Sworn and subscribed~ b~~re me this J9: . day of ~ ~6(j <-{ :.g' j~ Pr .~ " J~ 'S \Cl .---' NW %z ..-- . SHERIFF'S OFFICE . ,. 50 NORTH DUKE STREET, P.O, BOX 83480, LANCASTER, PENNSYLVANIA 17608.3480 . (717) 299.8200 Deborah J. Johnson aka Debra J. Johnson PLEASE TYPE DO NOT DEl ACH ANYCOPfES, . 2 COURT NUMBER 04-4776 civil 4 TYPE OF WRIT OR COMPLAINT Notice and Complaint SHERIFF SERVICE PROCESS RECEIPT, and AFFIDAVIT OF RETURN PlAINTIFF/SI HCR Manorcare Ine 3 DEFENDANT/SI { 5. NAME OF INDIVIOUAL. COMPANY, CORPORATION. ETC.. TO BE SERVED. Deborah J. Johnson aka Debra J. Jolmson 6. ADDRESS (Street or RFD, Apartment No., City, Boro, Twp" State and ZIP Code) 7. IN~~ATE UNUSUAL ~~R~Q6-~~;u~~~ 0 ~~~Raster, ttllt1~~~llU Now, 9/23/ 20 ~ , I, SHERIFF OF', " " COUNTY, PA., do her utile the Sheriff of Lancaster County to execute this Writ~ urn there~f a to law, This deputation being made at the request and risk of the plainliff, r.... ~ . - r" SHERIFF OF - cou -- 8, SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE, SERVE .. Cunberland ClJIIII''''IU lWT' C" NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching 8l1y property under within wril may leave same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without habilityon the part 01 such deputy or the sheriff to any plaintiff herein for any loss, destruction or removal of any such property before sheriff's sale thereof. 9. SIGNATURE of ATTORNEY or other ORIGINATOR 110. TELEPHONE NUMBER 111. DATE DAVID A. BARIII!: ESQ. 717-249-6873 9/22/04 12, SEND NOTICE OF SERVICE COpy TO NAME AND ADDRESS BELOW: (This area must be completed if notice is to be mailed). CUBMERLAND CO SHERIFF ONE COURTHOUSE SQ. CARLISLE PA. 17013 SPACE BelOW FOR USE OF SHERIFF ONLY - DO NOT WRITE BELOW THIS LINE 13 I k I d . 'I Ilh 'I f NAME of Authorized LeSO Deputy or Clerk 114. Date Received 115. Expiration/Hearing dale . ac nowe ge recelp 0 e wn olcomplaintasmdicaledabove, JACKIE MICCICHE 9/24/04 10/22/04 16. I hereby CERTIFY and RETURN that 1'-~""~rsOnaIlY served, 0 have legal evidence of service as shown in "Remarks", 0 have executed as shown in ~ "Remarks", the writ or complaint desc~vcirft~e individual, company, corporation, etc., at the address shown above oron the individual, company, cor- (J) paratian, etc., at the address inserted below by handing a TRUE and ATTESTED COPY thereof. () ~ named above. (See remarks below) o No Servioe See Remarks BeIaN (No. 30) <, 21. Date of Service 22, Time 0 /~/W I/.-~~ 150.00 36.50 I Milea, De., Int.I Dal. Mlle. 1 De.,lnl, 13T"J~ :SSg 129. ?r,DU,OLEFUND S.Tk wQ5Y; / (O'l-}O'-/, 31 AFFIRM~D subscribed to before me thIS ~yot ~<H- ',,-~ ",nn n \lC~ ~~ ~. AN~'~ ~ I. 32. Si.9.' nature 01 . . J~, 1t4, I ''''L./ 20 l. ~ Dep. Sheriff , -- , .,--, . _ _. y- 35 S"os'v" el She,ill .. 7!J 6 o"t1", I ~ 0' , . ":' -. HCR MANORCARE, INC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004- 4776 CIVIL TERM DEBORAH J. JOHNSON, aJk/a DEBRA J. JOHNSON, Defendant. CIVIL ACTION-LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this Amended Complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court, your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER, IF YOU CANNOT AFFORD TO HIRE A LA WYER, 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 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 HCR MANORCARE, INC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004- 4776 CIVIL TERM DEBORAH J. JOHNSON, aJk/a DEBRA J, JOHNSON, Defendant. CIVIL ACTION-LAW AMENDED COMPLAINT NOW, comes HCR ManorCare, Inc., ("ManorCare"), by and through its attorneys, O'BRlEN, BARlC & SCHERER, and files the within Amended Complaint and, in support thereof, sets forth the following: 1. HeR ManorCare, Inc, is an Ohio corporation duly authorized to conduct business in the Commonwealth of Pennsylvania with a business address of 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania. 2. Defendant, Deborah J. Johnson, a/k/a Debra J. Johnson, is an adult individual who resides at 25 Savo A venue, Lancaster, Lancaster County, Pennsylvania. 3. By a Power of Attorney dated November 26, 2002, Jean E. Albright appointed Deborah J. Johnson as her attorney-in-fact. A true and correct copy of the Power of Attorney is attached hereto as Exhibit "A" and is incorporated by reference. 4. ManorCare owns and operates a skilled nursing facility located at 1700 Market Street, Camp Hill, Cumberland County, Pennsylvania ("facility"). 5. On or about November 27,2002, Jean E. Albright sought admission to the ManorCare facility, 1 ~ . 6. In connection with seeking admission, Deborah J. Johnson met with ManorCare employees at the facility in Camp Hill and she executed an Admission Agreement by and through her power as attorney in fact for Jean E. Albright. A true and correct copy ofthe Admission Agreement is attached hereto as Exhibit "B" and is incorporated by reference. The Admission Agreement was signed at the facility in Camp Hill. 7. Jean E. Albright became a resident of the facility on November 27,2002 and remained a resident until the time of her death on November 16,2003. 8. On or about November 19, 2002, Jean E. Albright completed an Application for Residency provided by ManorCare. A true and correct copy of the Application for Residency is attached hereto as Exhibit "C" and is incorporated by reference. 9, In the Application for Residency, Jean E. Albright represented she was receiving Social Security income of $1 ,500.00 per month as of November, 2002. 10. From the date of her admission on November 27,2002 through the date of her death on November 16, 2003, the social security benefits of Jean E. Albright were being received by Deborah J. Johnson. Upon information and belief, these receipts totaled in excess of $18,000.00. II. Upon her admission to the facility, Jean E. Albright made application for medical assistance to pay a portion of her monthly costs of care at the facility. 12. Deborah J, Johnson failed and refused to provide the information requested by the Department of Public Welfare, County Assistance Office necessary to make a determination of benefit eligibility. 2 13. As a consequence of this refusal to provide the necessary information, the County Assistance Office denied benefits to Jean E. Albright. 14. A second application was made to the County Assistance Office and Jean E. Albright was deemed eligible for medical assistance benefits effective August 1,2003. 15. As a result of the failure to provide the requested information, when medical assistance benefits were finally granted in August, 2003, the Department of Public Welfare would not make the benefits retroactive to the date of admission. 16. The Admission Agreement provides, in relevant part, as follows: 1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 17. Costs for care ands services provided by ManorCare to Jean Albright remain unpaid in the amount of $17,395.28 all as more fully set forth on the Resident Ledger a true and correct copy of which is attached hereto as Exhibit "D" and is incorporated by reference. COUNT I-BREACH OF CONTRACT HCR MANORCARE, INC. v. DEBORAH J. JOHNSON 18. Plaintiff incorporates by reference paragraphs one through seventeen as though set forth at length. 19. All conditions precedent to recovery under the Admission Agreement have been fulfilled, 3 20. Deborah J. Johnson was obligated to use the assets and income of Jean E. Albright to satisfy the debt due and owing to ManorCare for the services and care provided to Jean E. Albright by ManorCare. 21. The Admission Agreement provides, in relevant part as follows: 2.01 Legal Authority. The legal representative hereby represents that he/she has legal access to the resident's income or resources and that the documents supporting such authority, if any, have been delivered to the center. 2.02 Agreement To Make Payments On Behalf Of Resident. The Legal Representative agrees to pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and charges provided for in this Agreement. 22. The amount due and owing is not covered by a third party payor. 23. Deborah J, Johnson has breached the Admission Agreement by failing and refusing to pay for the services and care provided from the assets and income of Jean E. Albright. 24. Late fees on the amount owed calculated from January 1,2004 to September 1, 2004 are $2,091.08 and will continue to accrue at the per diem rate of$8.57. WHEREFORE, Plaintiff requests judgment in its favor and against the Defendant for the sum of$17,395.28 plus late fees of $2,091.08 and any additional amount oflate fees accruing to the date of award, costs and expenses and attorney fees. 4 COUNT II-MONEY HAD AND RECEIVED HCR MANORCARE, INC. v. DEBORAH J. JOHNSON 25. Plaintiff incorporates by reference paragraphs one through twenty-four as though set forth at length. 26. During the period of Jean E. Albright's residency at the facility, Deborah J. Johnson received the sum of at least $18,000.00 in social security benefits paid to Jean E. Albright. 27. The proper use of these funds would have been to pay the costs of care accruing for the care of Jean E. Albright at the facility. 28. At the time of receipt of these funds, Deborah J. Johnson knew she was obligated to pay these funds over to ManorCare for the costs of Jean E. Albright's care at the facility. 29. Deborah J. Johnson gave no consideration for the funds of Jean E. Albright received by Deborah J. Johnson. 30. Demand has been made upon Deborah J. Johnson to tender the funds of Jean E. Albright and she has failed and refused to do so. 5 WHEREFORE, Plaintiff requests judgment be entered in its favor and against Deborah J. Johnson requiring her to: a) return the subject matter in specie; b) pay over the value if Deborah J. Johnson has consumed the money in beneficial use; c) pay its value if Deborah 1. Johnson has disposed of the funds received; and d) award costs, expenses and interest. Respectfully submitted, David A. Baric, Esquire J.D. 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Attorney for Plaintiff dab.dir/manorcare/albright/complaint2. pld \'/!;\r/'r7/~,S\r\J~i :1 I " ,,~ """, " -, '.'0_" '''..... l\ll'li 'I." ' "',;, 'J; iv r 1 :01 k'~ C- ADN ryDGl AbV10NO,LJiOdd 3Hl :10 30L:!.:iG-Q31l.:! VERIFICA nON I verify that the statements made in the foregoing Amended Complaint are true and correct to the best of my knowledge, information and belief. This verification is signed by David A. Baric, Esquire, Attorney for Plaintiff and is based upon the statements provided by Plaintiff, as well as documents reviewed by the undersigned as attorney for Plaintiff. This verification will be substituted and ratified by a verification signed by the Plaintiff who is presently unavailable to sign said verification. I undersigned that false statements herein are made subject to penalties of 18 Pa.C.S. ~4904, relating to unsworn falsifications to auw I David A. Baric, Esquire Dated: /I/03/of I I G:\Uscrs'ajo\GGK\albrighl.jcan,poa, \\pd: II ~ 1 0: POWER OF ATTORNEY NOTICE - THE PURPOSE OF THIS POWER OF A TIORNEY 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 APPROV AL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY O~ YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND Ii\ ACCORDANCE WITH THIS POWER OF A TIORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAP ACIT A TED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEP ARA TE 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 A TIORNEY ARE EXPLAINED MORE FULLY IN 20 P A. 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. Dated: \ \ . ~ C:,- 0 J.. her Jean E. X' AlbrilZht mark I, Jean E. Albright, of820 Lisburn Road, Apartment 806, Camp Hill, P A 17011-7106 do hereby appoint Debra J. Johnson 25 Savo Avenue, Lancaster, PA 17601-3937 as my attorney-in- fact with power to transact any business at all in my name as though I myself were acting. . This power includes, but is not limited to, the following: \ 1. To write checks, and to execute and deliver payment and withdrawal orders on any accounts that I may have with any bank or other similar institution, and to deliver the checks or money paid or withdrawn to any person, group of persons, or associations; and to endorse checks or other instruments for deposit or collection; 2. To take all lawful steps to recover, collect and receive any amounts of money now or hereafter owing or payable to me, and to compromise and execute releases or other sufficient discharges for them; EXIilBI7 "A" .. 3. To withdraw and receive the income or corpus of any trust; 4. To sue and settle suits of any kind in my name or for my benefit; 5. To buy, sell, mortgage, hypothecate, or grant security interests in any kind of tangible or intangible personal property; - 6. To sign, assign or endorse any security issued by any corporation, bank or other organization and to exercise any rights with respect thereto that I may have; 7. To lease, sell, release, convey, extinguish or mortgage any interest in real property on such terms as may be deemed advisable; and to manage, repair, improve, maintain, restore, build or develop such property; 8. To purchase or otherwise acquire any interest in and acquire possession of real property and to accept all deeds and other assurances in the law for such property; 9. To execute, deliver, and acknowledge deeds, deeds of trust, covenants, indentures, agreements, mortgages, hypothecations, bills of lading, bills, bonds, notes, receipts, evidences of debts, releases and satisfactions of mortgage, judgment, ground rents and other debts; 10. To enter my safe deposit boxes and to open new safe deposit boxes, and to add to or remove any of the contents of any such safe deposit boxes, and to close out any of the boxes; II. To borrow money for my account on whatever terms and conditions may be deemed advisable, includiqg the right to borrow money on any insurance policies issued on my life for any purpose, ~nd to pledge, assign, and deliver such policies as security; 12. To make limited gifts. Ifmy foreseeable needs are amply provided for, my Agent may make gifts for me and on my behalf in amounts not in excess of and in a manner to qualify for the a~nual exclusion from Federal Gift Tax permitted under Section 2503(b) of the IRe; provided that the permissible donees shall be limited to my spouse and my issue. My Agent may make gifts to ~ny one or more of such donees either outright or in trust. In the case of a gift to a minor, such gift may be made in trust or in accordance \\ith the appropriate state Uniform Transfers to Minors Act or similar statute. In the case of a gift made in trust, my Agent may execute a tru~t agreement for such purpose, designating one or more persons (including my Agents) as the original or successor trustees, or may make additions to an existing trust. No transfer agent, depository or other third party acting in good faith shall have any responsibility to see to the proper discharge by my Agent of any duties hereunder. In making any gifts, my Agent need not treat the donees equally or proportionately and may entirely exclude one or more persons; 2 " 13. To prepare, execute and file all tax returns required to be made by me, to pay the taxes due, to collect any refunds, to sign waivers extending the period for the assessment of such taxes or deficiencies in them, to sign consents to the immediate assessment of deficiencies and acceptances of proposed overassessments, to execute closing agreements, and to engage and appoint attorneys to represent me in connection with any matters arising before any federal, state or local taxing agency; 14, To disclaim any interest in property; 15, To renounce fiduciary positions; 16. To arrange for my entrance to and care at any hospital, nursing home, health center, convalescent home, retirement home, or similar institution, and to arrange for, consent to, "vaive and tenninate any and all medical and surgical procedures on my behalf, including the administration of drugs, and to pay all bills for my care; 17. To create a trust for my benefit and to make additions to an existing trust for my benefit. I do hereby ratify and confirm all that my attorney-in-fact and a substitute or successor shall lawfully do, or cause to be done, by virtue of this Power of Attorney. This Power of Attorney shall not be affected by my physical or mental disability or incapacity or by uncertainty as to whether I am dead or alive, and it may be accepted and relied upon by anyone to \vhom it is presented until such person either (1) receives written notice of revocation by me or a guardian (or similar fiduciary) of my estate, or (2) has actual knowledge of my death. . My ~ttorney-in-fact shall be ~ntitled to reasonable compensation for services performed hereunder. IN WITNESS \VHEREOF, I, Jean E. Albright, being unable to sign my name because of \!\ health, baye ad my named subscribed for me in the, presence and at my direction by , whereupon I have made my mark, unassisted, in the space between \0 day of November 2002. her Jean E.X Albriszht(SEAL) mark .., :> On this -.alp _day of November 2002, Jean E. Albright, the above-named indi vidual, in 'our presence, declared the preceding instrument, consisting of this and three (3) other typewritten pages, to be her Letter of Attorney and being unable to sign her name hereto because of ill health directed her name to be subscribed for her which the undersigned, M\Jltl J . ~ ,did subscribe as directed in the presence of Jean E. Albright, .... in our presence, unassisted, make her mark or cross in the space provided between her names and we, in the presence of Jean E. Albright, and in the space provided between her names, and we, in the presence of Jean E. Albright, and in the presence of each other, at the request of Jean E. Albright, have subscribed our names as witnesses. /: ~~~ residing at d /i'rt. &<~ J3. /. #~~~~l / -- <-- residing at_ ~L7dr~~ &- ~~~~ residing at ~ \\\\\ I ~~ COMMON\VEAL TH OF PENNSYLVANIA COUNTY OF LANCASTER ) ) SS: ) On this, the c1.Le day of November 2002, before me, a Notary Public, personally appeared Jean E. Albright, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument and acknowledged that she executed the same for the purpose therein contained-. \ IN W1lNESS WHEREOF, I hereunto set my hand and official seal. NOTARIAL SEAL LINDA l. WEAVER. Notary Pu I Lower AUen Twp.. Cumberland Co., PA \. """l'Il1lssion Expires Oct. , 3 2003 L.-, '_,_',~_ 4 1.,/ '. AGENT'S ACKNOWLEDGMENT I, Debra J. Johnson, have read the attached Power of Attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specific - provision to the contrary in the Power of Attorney or in 20 Pa. C.S. when 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 my 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. Dated: \ \. d.c, -~ ~ tJ L_ ~,L Debra J, Johnso \ HCR Manor Care Pennsylvania ADMISSION AGREEMENT This Agreement is entered into by and among, d.b.a. HCR Manor Care, ("HCR Manor Care"), the Resident, and the Responsible Party, if any, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Health Care Center ("Center"), Center: HCR ManorCare.Camp Hill Resident: Jean E. Albright Legal Representative: Debra Johnson Deposit: $ ~ Admission Date: 11/27/02 Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged, I. RIGHTS AND RESPONSffiILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.95) or by a Third Party Payor or Managed Care Organization (see Section 1.06). 1.02 Ancillary Charges, The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours, Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. EXliIEI7 "E" 1.03 Late Payments. Accounts not paid in full within thirty (30) days of billing shall be subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident shall be directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program, 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same tenns and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program( s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: ./ Medicare, ~ Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room: and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1,06 Third Party Payors and Managed Care Organizations, If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization (liP SO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents, If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 " will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident and/or Legal Representative acknowledge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Infonnation. It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed infonnation regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium( s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such infonnation, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failute to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 PrimaIy Responsibility for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to bill a third party, The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors, This 3 " Agreement serves as a written notice that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. 1. 11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of hislher personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system, ll. RIGHTS AND RESPONSmILITY OF THE LEGAL REPRESENTATIVE 2.01 Legal Authority. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Legal Representative agrees to pay promptly ftom the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and charges provided for in this Agreement. 2.03 Requested Items. The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. 2,04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 4 2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such infonnation about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Responsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments, m. RIGHTS AND RESPONSmILITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. :The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Infonnation. The Resident and/or Legal Representative hereby consents to the release of hislher medical records to the following persons: Center personnel, attending physicians and consultants; and person, :firm, government entity, third party payor or managed care organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance 5 .. reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. f. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds, A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds 6 " Authorization and any other related documents. See Attachment H-I and H-2. g. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). h, Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). 1. Name, address and phone number of Ombudsman, See Attachment I (Center Supplement). J. The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). k. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement). I Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. See Attachment I (Center Supplement). m. The Resident Handbook. See Attachment 1. n. ResidentlPatient Rights. See Attachment K. o. MedicareIMedicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-I and M-2. q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment 0, 7 : s. ASM Form, See attachment P. 1. See Attachment Q. u. See Attachment R. v, See Attachment S. w. See Attachment T. x. See Attachment U. y. See Attachment V. z. See Attachment W. 4.05 Assignment of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer, This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room arid Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property 8 " of any person or entity (including the Center). except in the case of negligence of the Center's employees and agents. 4.08 Changes in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Agreement and. it is agreed that to the extent possible. the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law, THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature of Legal Representative. if signing on behalf of Resident: i2J_~ ~ ~~ Date: II-'<'\-OJ. Signature of Legal Representative. signing on hislher own behalf: Date: Center Representative: ~ . . 'v'\. S\o~, Date:~ 9 .. ATTACHMENT A ROOM AND BOARD RATE The Resident shall pay the following monthly rate: Semi-Private Room: Private Room: 3-Bed Room: 4-Bed Room: Subacute Semi-Private Room: Subacute Private Room: 3-Bed Room: 4-Bed Room: The rate of interest assessed on overdue accounts is U%, the highest amount permitted by state law in Pennsylvania. . . 10 " ATTACBMENTB ANCILLARY CHARGES The services and supplies categorically described on this Attachment are not included in the basic Room and Board Rate. Therefore, the Resident will be individually billed for these items in accordance with Section 1.02 of the Admission Agreement. A complete list of ancillary items, together with the current price, is on file at the Center's business office. Personal laundry and dry cleaning, Personal care items, such as toothbrush, toothpaste, mouthwash, deodorant, hairbrush, Efferdent, tissues, razors, etc. Beauty and Barber Shop services Tobacco and smoking supplies, newspapers and periodicals Stationary, postage, and writing implements Radios, televisions, cable service, room telephone Transportation for non-medical purposes and ambulance charges Photocopies of medical records Personal physicians and specialists Dental services and Dentures Optometrist/Ophthalmologist services and Eyeglasses Podiatry services Special nursing services, such as hand feeding, and care for catheters, decubit~ incontinence, isolation and dressings Therapy services, including physical, speech, occupational, audiology and respiratory therapy Prescription and non-prescription medication Laboratory and x-ray tests Oxygen and related supplies IV Therapy and supplies Peritoneal dialysis Tracheotomy supplies Ventilator rental and related supplies Medical supplies, including but not limited to syringes, dressings, catheters, colostomy bags, tubes, surgical stockings, and all other supplies necessary for the treatment, nursing care, or well-being of the Resident Incontinence supplies Special equipment (for some items, a rental, rather than purchase fee is charged), such as wheelchairs, wheelchair pad, trapeze, canes, geri-chair, special mattresses, porta-chairs, etc, Special, supplementary, or very low calorie prescription dietary products, including liquid for gastric and naso-gastric tubes, and any supply necessary to accomplish special feedings. 11 .' ATTACHMENT C AUTHORIZATION FOR RELEASE OR REVlEW OF MEDICAL INFORMATION . . 12 : 1/( R \lll/lOl' ( 1I1't' Authorization for Release or Review of Medical Information Authorization is hereby granted for a: Record Review Name of Reviewer Release of Information To: From: Patient's Name: Albright, Jean E Patient's Name Albright, Jean E Admission Date 11/27/02 Discharge Date [1:- '.I~ D.O.B. 5/3/16 Copies Requested Final Diagnosis Diagnosis Summary History and Physical Examination X-Ray Reports EKG Reports Laboratory Reports Nursing Notes '. Physical Orders Psychiatric Other (please Specify) This consent will expire on or sixty days after the date below or sooner, at my discretion. Patient's Signature Date Ie Party Signature Date \, \2:1 \0 Date ...., \. '-, 0 <: sary only when the patient has a guardian or is unable to sign Resident Name: Albright, Jean E Medical Record #: 1310 13 ATTACHMENTD AUTHORIZATION FOR PAYMENT OF BENEFITS 14 .. HCR Manor Care AUTHORIZATION FOR PAYMENT OF BENEFITS RESIDENT'S NAME: Albriaht. Jean E SOC. SEC. NUMBER: 187-05-0089 ADMISSION DATE: 11/27/02 MEDICARE NUMBER: 187050089A I, Albriaht. Jean E, authorize and request my insurance company, third party payer or governmental payer to pay directly to HCR ManorCare-Camp Hill for nursing care benefits rendered to me or my named dependent. The type of services requested are: skilled nursing facility 1 nursing facility 1 needed ancillary services. I also authorize the release of medical information necessary to process this claim. I understand that this authorization applies to those eligible charges for which I am covered by my insurance company's benefit or third party payer and that any additional and/or denied charges are entirely payable by me. , , A copy of this will serve as an original. Signature of Resident Date ~~._b \, ~ ~c~~ And/Or Legal Re'pre nt ve \\.'1,.o~ Date (Copies to Resident/Legal Representative and Center.) Resident Name: Albright. Jean E Medical Record Number: 1310 15 .. A'ITACHMENTE SOCIAL SECURITY ADMINISTRA nON APPOINTMENT 16 .. IICR l!lI/10}, ClIre SOCIAL SECURITY ADMINISTRATION NAME (Claimant) (Print or Type) SOCIAL SECURITY NUMBER Albright, Jean E 187-05-0089 SOCIAL SECURITY NUMBER WAGER EARNER (if different) Section I APPOINTMENT OF REPRESENTATIVE I appoint this individual 'Ih", \)(.,-\'Ce...\ 1'iT" ~.\\~ ( Name and address) to act as my representative in connection with my claim or asserted right under: D Title II D Title XVI D Title IV FMSHA ~ Title XVIII (RSDI) (551) (Black Lung) (Medical Coverage) I authorize this individual to make or give any request or notice; to presen r elicit evidence; to obtain information; and to receive any notice in connection with my pending claim or asserted right wholly in my stead. SIGNATURE ( ADDRESS ~ ~ Section II I, , hereby accept the above appointment. I certify that I have not been suspended or prohibited from practice before the Social Security Administration; that I am not, as a current or former officer or employee of the United States, disqualified from acting as the claimant's representative; and that I will not charge or receive any fee for the representation unless it has been authorized in accordance with the laws and regulations referred to on the reverse side hereof. In the event that I decide not to charge or collect a fee for the representation, I will notify the Social Security Administration. (Completion of Section III satisfies this requirement.) I am a/an (Attorney, union representative, relative, law student, etc.) SIGNATURE (Representative) ADDRESS , . TELEPHONE NUMBER DATE (Area Code) Section III (Optional) WAIVER OF FEE I waive my right to charge and collect a fee under Section 206 of the Security Act, and I release my client (the claimant) from any obligations, contractual or otherwise, which may be owed to me for services I have performed in connection with my client's claim or asserted right. I SIGNATURE (Representative) I DATE _ WAIVER OF DIRECT PAYMENT I ONLY waive my right to direct certification of a fee from the withheld past-due benefits of my client (the claimant). I do NOT, however, waive my right to petition for and be authorized to charge and collect a fee directly from my client. I SIGNATURE (Representative) I DATE Form SSA-1696-U4 (3-88) (See Important Information on Back of Last Copy) 17 HOW TO COMPLETE THIS FORM Print or type your full name and your Social Security number. Section 1 - APPOINTMENT OF REPRESENTATIVE You may appoint as your representative an attorney or any other qualified individual. You may appoint more than one person, but see "The Fee You Owe The Representative(s): You may NOT appoint as your representative an organization, the law firm, a group, etc. Example, you go to a law firm or legal aid group for help with your claim, you may appoint any attomey or other qualified individual from that firm or group, but NOT the firm or group itself. Check the block(s) for the program in which you have a claim. Title II, check if your claim concerns disability or retirement benefits, etc. Title XVI, check if the claim concerns Supplemental Security Income (551) payments. Title IV FMSHA (Federal Mine Safety and Health Act), check if the claim is for black lung benefits, Title XVIII, check only in connection with a proceeding before the Social Security Administration invoMng entitlement to medicare coverage or enrollment in the supplementary medical insurance plan (SMIP). More than one block may be checked. Section II - ACCEPTANCE OF APPOINTMENT The individual whom you appoint in Section I above completes this part. Completion of this section is desirable in all cases, but it is mandatory only if the appointed individual is not an attorney. 1. When will the representation stop: We will stop recognizing or dealing with your representative when (1) you tell us that he/she is no longer your representative; (2) your representative does anyone of the following: (a) submits a fee petition, or (b) tells us that he/she is withdrawing from the claim, or (c) he/she violates any of our rules and regulations, and a hearing is held before an administrative law judge (designated as hearing officer) who orders your representative disqualified or suspended as a representative of any Social Security claimant. 2. The fee you owe the representative(s): Every representative you appoint has a right to petition for a fee. To charge you a fee, a representative must first file a fee petition with us. Irrespective of your fee agreement, you never owe more than the fee we have authorized in a written notice to you and your representative(s). (Out-of- pocket expenses are not included). If your claim went to court, you may owe an additional fee for your representative's services before the court. 3. How we determine the fee: We use the criteria on the back of the fee petition (Form SSA 156O-U4), a copy of which your representative must send you. Section III (Optional) - WAIVER OF FEE This section may be completed by your representative if he/she will not charge any fee for services performed in this claim. If you had appointed a co-<:ounsel (second representative) in Section I and he/she will also not charge you a fee, then the co-counsel should also sign this section or give a separate waiver statement. GENERAL INFORMATION 1. When you have a representative: We will deal directly with your representative on all matters that affect your claim. Occasionally, with the permission of your representative, we may deal directly with you on specific issues. We will rely on your representative to keep you informed of the status of your claim, but you may contact us directly for any information about your claim. 2. The authority of your representative: Your representative has the authority to act totally on your behalf. This means he/she can (1) obtain information about your claim the same as you; (2) submit evidence; (3) make statements about facts and provisions of the law; and (4) make any request (including a fee request). It is important, therefore, that you are represented by a qualified individual. 3. Review of the fee authorization: If you or your representative disagrees with the fee authorization, either of you may request a review. Instructions for filing this review are on the fee authorization notice. 4. Payment offees: If past-due benefits are payable in your claim, we generally withhold 25 percent of the past-due benefits toward possible attorney fees. If no past- due benefits are payable or this is an SSI claim, then payment of the fee we have authorized is your responsibility. 5. Penalty for charging an unauthorized fee: If your representative wants to charge and collect from you a fee that is greater than what we had authorized, then he/she is in violation of the law and regulations. Promptly report this to your nearest Social Security office. 18 ATTACHMENT F SNF MEDICARE DETERMINATION NOTICE . . 19 HCR- ManorCare SKILLED NURSING FACILITY DETERMINATION (For ADr.lISSION or CONTINUED STAY denial) SNF Name: HCR ManorCare-Carro Hill DATE: _1_1_ TO: Name: Debra Johnson RE: Beneficiary Address: 25 Saw Avenue City, State, Zip: Lancaster. PA 17601 Address: 1700 MarXet Street Carro Hill. PA 17011 Jean E. A1briaht Admission Date: 11127102 Medicare Number (HICfI): 187050089A I TECHNICALLY INELIGIBLE ADr.lISSION On \ _ , we revieNed YOIJ' medical information available at the tine of, or prior to adnission, and we believe that the service(s) ( beneficicly ncme) needed tid not meet the requirements fa' coverage under Medca'e. The reason is: o You had no 3 day hospital qualifying stay o You have previously exhausted YOlX 100 Medcare days coverage and remained at a Mecficare skilled level of care o You are not entitled to Medicare Part A o Your clischarge from the hospilallSNF has exceeded 30 days \b- If the resident is waiving Medicare benefits complete the "Voluntary Waiver of Medicare Benefits' Letter" II ADr.lISSION or CONTINUED STAY - SKILLED CARE DENIAL IJ Facility Decision IJ Utilization Review Committee DecIsion On I I , we reviewed your mecical information and found that the seMces furnished (you) no longer qualified as covered under Meacare beginning I I The reason is: o You have used the full 100 days of Medicare coverage allowed under the Medeare program for Skilled Nursing facility coverage. o Medcare covers medically necessary skilled nursing care needed on a daily basis. You only needed oral medeations, assistance with your daily activities and general s~ services. There is no evidence of medeal complications or other medeal reasons that required the skills of a professional nurse or therapist to safely and effectively cany out your plan of care, Therefore, we believe that your care cannot be covered under Medicare, o Medicare covers medically necessary skilled care needed on a daily basis, You only needed , This does not require the skills of a licensed nurse to perform the service or to manage your care, Since you needed neither skilled nursing nor skilled rehabilitation on a daily basis, we betielle your stay is not covered under Medicare, o Medicare covers mecically necessary skilled care needed on a daily basis. You only needed after I I Since you no longer require skilled nursing and lid not need skilled rehabilitation on a daily basis, we believe your stay beginning I I is not covered under Medicare, o Medicare covers meacally necessary skilled care needed on a daily basis, You needed skilled nursing care beginning I I to obselVe and evaluate your condition. There is no indication of further likelihood of significant changes in your care plan or of acute changes or complication in your condtion, Since you no longer need skilled nursing or skilled rehabilitation services on a daily basis, we believe your stay after I I is not covered under Medcare, o Medicare covers medically necessary skilled care needed on a daily basis, Because of your condtion you needed a skilled nurse from I I through I I to eIIaluate and manage your care plan, Your condition has improved so the services you need can safely and effectively be given by non skilled persons, Since you no longer require skilled nursing and lid not need skilled rehabilitation services on a daily basis, we believe your stay is not COIIered under Me<icare after I I o Medicare covers medical necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time where progressive learning is demonstrated, You have learned to perform the tasks ordered by your physician by I I butlhe therapist continued services, Since you did not need skilled selVices after that date, we believe your stay is not covered under Medicare beginning I I o Medicare covers medical necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time where progressive learning is demonstrated, You needed only to be reminded to follow the physician's instructions, This does not require the skills of a professional nurse or therapist. Therefore, we belielle thatlhis service is not COVeled under Medicare, . 0 Medicare covers mecically necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time where progressive learning is demonstrated, You received teaching and training for a reasonable time but demonstrated you were not able, at this time, to learn or make progress to perform the activities ordered by your physician, Therefore, we belielle that skilled services are not covered under Medicare after I I 20 o Medcare covers daily skilled nursing care related to the insertion, sterile irrigation and replacement of urethral catheter if the use of the catheter is reasonable and necessary for the active treatment of a dsease of the urinary tract or for patients with special medical needs, Skilled nursing is not considered me<ically necessary when urethral catheters are used only for mere convenience or the control of incontinence, Since your catheter was inserted for convenience or the control of your incontinence, We believe that your care is not covered under Medcare, o Medcare covers medically necessary skilled rehabilitation services, The medical information shows that the only therapy services you needed beginning I I were repetitive exercises and help with walking, These do not generally require the skills or the supervision of a ~ therapist There was no evidence of medical complications which would have required that services be performed by a qualified therapist. We believe therapy services are not covered under Medicare after / / o Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis The therapy services you received were for your overall fitness and general well-being, They did not require the skills of a qualified therapist to perform and / or to s~e the services, Since you <id not need skilled nursing or skilled rehabilitation services, we believe your stay is not covered under Me<icare, o Medicare covers medcally necessary skilled rehabilitation services to establish a safe and effective program to maintain your functional abilities, This program was established and beginning / I , the therapy services you received were to carry out this program, These services do not require the supervision or skills of a therapist and, therefore, we believe that the services are noV would not be covered under Medicare, o Medicare covers medically and necessary skilled care when needed on a daily basis, The (specify services) you received is/are considered a skilled service by Medicare. However based on the medical information prOYided, thislthese services(s) is noVare not considered a specific and lor effective treatment for your condition, Since the services(s) you received was nollwere not reasonable or necessary for the treatment of your condtion, we believe your stay is not covered under Medicare, o Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis, The therapy services provided was notlwere not reasonable in relation to the expected improyement in your condition, In this case, since you do not need skilled nursing on a daily basis and the therapy services are not considered reasonable and '1ecessary, we believe, your stay is not covered under Medicare, o Medcare covers medically necessary skilled rehabilitation services when needed on a daily basis. While you required skilled from / / to I I , the medical information shows that the therapy services after that time are not reasonable in relation \0 the expected improvement in your condition. In this case, since you do not need skilled nursing on a daily basis and the therapy services are not considered reasonable and necessary, we believe, your stay after / / is not covered under Medicare. o Medicare covers medically necessary skilled care when needed on a daily basis. Although (service) generally requires the skills of a the frequency with which the service is given must be in accordance with accepted standards of medical practice, The service(s) you received is noVare not normally needed on a daily basIS, The medical information does not show medical complications which require the services to be performed on a daily basis. In this case, the services are not considered reasonable and necessary, Since you did not need skilled nursing or skilled rehabilitation on a daily basis, we believe your stay is not covered under Medicare. This decision has not been made by Medicare. It represents [] our (or) [] the Utilization Review Committee's judgnent that the services you needed did not meet or no longer met Medica"e payment requirements. A bill will be sent to Medicare for 5efVices you received before I I . Normally, the bill submitted to Medicare does not include services provided after this date. If you want to appeal this decision, you must request that the bill submitted to Medicare include the services we determined to be non-rovered, Medcare will notify you of its determination, If you oJSagree with that determination you may file an appeal. : III NON-CERTIFIED BED PLACEr.1ENT CONSENT [J We are placing you in a part of this facilily which is not appropriately certified by Medicare because you do not require a level of care that will qualify as skIlled nursing care, Nonqualifying services furnished a patient in a non-certified or in appropriately certified bed are not payable by Medicare. . IV APPEAL RIGHTS Under a provision of the Medicare taw, you do not have to pay for noo-covered services determined to be custodal care or not reasonable and necessary unless you had reason to knew the services were non-<:oIIered. You are considered to know that these services were non- covered effective with the date of this notice. If you have questions concerning your liability for payment for services you received prior to the date of this notice, you must request that a bill b e submitted 10 Medcare. We regret that this may be your first notice of the non-coverage of services under Medicare. Our efforts to contact you earlier in person or by telephone were unsuccessful. Please check one of the boxes below to indcate whether or not you want your bill submitted to Medicare and sign the notice to verify receipt. Sincerely yours, Signature of Acministrative Officer 21 V REQUES1 FOR f.1E::DICARE INTERf.1EDIARY REVIEW o A. I do want my bll fa' services I continue to receive to be St.tmitted to the interTnelBy fa' a Medan decision. You MI be inbmed v.4len the bill is stbnitted. If you do not receive a formal Notice of Mecicare Determination wilhin 90 days of this request you should contact C MninaStar Federal IJ CareFirst (Blue Cross of Maryland) IJ 801A W. 811 Sl 1946 Greenspring Dr. Cincinnati. O. 45203 Timonium, Md. 21093 Name and Ada'ess of IntenT1ecBy o B. I do not want my biD fa' services I continue to need to be Slbnitted to the Interrnedary fa' a Medicare decision. I understand that I do not have Medcare riSIlls if a bin is not Stbnitted. Note: Beginning October 1, 1989, you In not requFed to pay fa' services v.tlich could be covered by Medan until a decision has been made. VI VERIFIC,4 TION OF RECEIPT OF NOTICE o C. This acI<no\Wldges that , received this notice of non coverage of services under Meclcare on I I SignallJ'e of Resident 01' person acting on Residenfs behalf If not sigled by Resident indcate relationship to Resident o D. This is to conlim that you were advised of the non- coverage of the services under Mecicn by telephone on I Name of person contacted and relationship to the Resident Signature of Mninistrative Officer cc: 1. AttencIng Physician 2. Patienfs Financial Record KEEP A COpy OF THIS FOR YOUR RECORDS 22 ;>.,"-; .'.-,' .~~1.;>~:~-_. ' . . Skilled Nurs'n' ... :F.a~I~~l)itilTii.l"8Jl6n':: .~~< (Medicare N~ce:'.orNonC6v'figj)1~~>:t:~ . Puroose: 1. To notify the patient/resident, in writing as requirecl by federal regulation, that the care and services he/she requires no longer qualifies for Meclicare coverage Procedure: Names and Addresses 1. Enter the name of the facility and the facility's address 2. Enter the date the letter is being draftecl (this should be the same date that the notice is given in person or by telephone) to the resident/patient or the responsible party. 3. Enter the name and address of the person who is to be notified. 4. Enter the name of the resident/patient in the "RE: Beneficiary" area. 5. Enter the date the resident/patient was admittecl for this Medicare covered period. 6. Enter the resident/patient's Medicare number. Section I. Technically Ineligible Admission This section should only be completed if any of the described conditions apply to the resident/patient's admission. If this section is appropriate and completed the following sections must also be completecl: III. Non-Certified Bed Placement Consent VI. Verification of Receipt of Notice. * Cross out sections II. IV. and V. . Section II. Admission or Continued Stay - Skilled Care Denial Reason 1.This section is necessary when a resident/patient is technically eligible for Medicare coverage but does not meet the care requirements either because- there are no skilled care and services or because the care and services are no longer reasonable or necessary; e.g. the patient has stabilized into a safe pattern of chronic or custodial care. 2. Select the one (1) paragraph that best describes the reason the resident/patient no longer qualifies for skilled Medicare covered care. 3. When notifying a resident/patient that he or she no longer qualifies for Medicare the following sections of this form must be comoleted: A. Names and Addresses B. Section II"Adm/sslon or Continued Stay - Skilled Care Denial Reason" C. Section III. "Non-Certified Bed Placement Consent" (If the resident will be movecl to a bed which is not certified by Medicare. D. Section IV. "Appeal Rights" - Signed by the Administrator E. Section V. "Request for Medicare Intennedlary Review" Section III - "Non-Certified Bed Placement Consent" - This section must be completed if the resident/patient is to be move to a bed that is not certified for Medicare. Section IV. - "Appeal Rights" - This section should be completed and signed by the Administrator only when the letter is being given to a resident/patient who is technically qualified for Medicare coverage but oes not meet the care and services requirements for continued Medicare coverage. Section V. - "Request for Medicare Intermediary Review" This section should be completed only hen the letter is being given to a resident/patient who is technically qualified for Medicare coverage but does not meet the care and services requirements for continued Medicare coverage. 1. Selection "A" or "B" must be completed. 2. In selection "A" the appropriate Intermediary must be designated 23 3. If the resident/patient or responsible party selects "A" the business office must be infonned and directed to file a ~Demand' or .Patient Insist" bill- . Section VI. 'Verification of Receipt of Notice" - This section should be completed only when the letter is being given to a resident/patient who is technically qualified for Medicare coverage but does not meet the care and services requirements for continued Medicare coverage. 1. If the resident/patient or responsible party receives the notice in person, complete selection "C" and have the person notified sign the receipt section indicating only that they have received this notice. 2. If the resident/patient or responsible party receives the notice by telephone complete selection "0" and send a copy of the notice to the person contacted via a service that provides a signed receipt; e.g., certified mail, courier service, Federal Express, et al. Quick Reference 1. Admission has no three (3) day qualifying stay or does not have Medicare Part A coverage, complete: A. "Names and Addresses" B. Section I "Technically Ineligible Admission" C. Section III "Non-Certified Bed Placement Consent" D. Section VI. "Verification of Receipt of Notice" 2. Admission or Continued Medicare covered stay is deemed no longer eligible for Medicare complete: A "Names and Addresses" B. Section I "Technically Ineligible Admission" C Section II "Admission or Continued Stay - SlcJlled care Denial Reason o Section III "Non-Certified Bed Placement Consent" E Section IV. "Appeal Rights" F Section V. "Request for Medicare Intermediary Review G Section VI. "Verification of Receipt of Notice" coverage; 3. Letter distribution: A. Original should be filed in the resident/patient's financial record. B. Copy number one (1) should be given to the resident/patient or responsible party. C. Copy number two (2) should be given to the attending physician. 24 AITACHMENT G MEDICARE SECONDARY PAYOR OUESTIONNAIRE 25 IIi 1\ \1111/(11 ( 11/ (' MEDICARE SECONDARY PAYOR QUESTIONNAIRE BENDI~Y- iNFO~nf)~'~~~~~1~f~~~;~~~:*~.2;~::~rl.:~~~~~~:~~~; ~:.?~~1~.~.;~~ Medicare Beneficiary: _ Jel\,^ -I\\~ t' \ (~vd- Patient Acoount #: Dates of Service From: \\,2..1102- Through: Name of Person Who Supplied the Information: j~ ~\ 'n~\~ \r~ Provider Repn:sentative Name: ~~ ~ffi~ r i"slt> mc#: OCN: Relationship to Patient: \'\. \ ~ c.e... Input Date: 1. , '., . ' .WO~ 'COIWP~NS~~ON;';~~;;':;i41t*~~t~;R&':~-'i1\i\:'{;~:}?:(~':. ~fU:_'r%~~.:;':':. Per the patient, should this illnessfmjury be covered by a Workers Compensation claim? PLACE Y OR N 1 '\ HYes, this should be an MSP or c:onditioaal dalm, not Medicare Primary. YES or NO rv 0 What is the claim number? What is the original date of injury? What is the name of the Workers CompensatiOll plan? What is the address? city? State? Zip? ....;.... ,:(;:t.*~;.~;~:~.~i~~.'~~\~>;'~~~~1.t;5'\:~;~~_~<:~::_'- ':~:'3:.:'~:~':1~__~1J4Cl(.:~lJt(~:f~~ii~~~~~~1~~:i~1~~~::~~~-i ~~~(~:?:1r:;~r~)?H~~~~~~:f:~ 2. Is the patient covered by the Federal Black Lung program? YES or NO If Yes, an: any of the claim's diagnosis codes OIl the Departmeut of Labor's acc:eptable diagnosis code list? HYes, tills IIaouId be an MSP or COIIIIItloa81 dalm, not MedIcare~. Black would not cover SNF (J YES or NO - _ :~:~~.~:.~~~~.~~t'~.~'~'t:}~:~:J>~~;Yfi}t~:~t~~~;:.i~~~~~~~t~:P~~~iQ'~\~~$~~_~~~~if;~~~~~t~~~~~~~i~~}~~~tl~1'i;;' 3. Is the patient entitled to bmefits through the Depar1menl ofVdcnms AfliUrs? If Yes, does the patient WllDl the VA to be cootacted for authorizatiOll oftbese services? YESorNO ~ YES or NO '-~_~:'?"~;' .~.~~ ;':.: :~":~:f:~::~~~~:;~~~H~;~~Xt~,~~~::!~~t~~~~~::.-..~ _~- ','.::P11BQP~tIl'P.VICJ;~~It~~~t~~~~i~~~ti?~~~i.lt~~~~~~~~~~~~t;~j;.:t 4. Are the services covered by a public health service? If Yes, what is the name of the public health service? What is the address? City? State? What is the date of the services covered by the public health service? SNF does not ba PHS YESorNO N d Zip? . ..... t:~~::~!..~~;i:~AC~Elfl' '~~f:}:;:!:~.~~_ff;:f~f~~:.~;~r;,~~!~~Jf~~~~:5:~~1~~~~:~~.~~~~~~~~:~_~~f~~ry ';".~fli~~/~;Z(::.:~:.: S. Are these services the resuh of an accident? If Yes, what type of accident was this (For example: Auto, slip and fall [Please list locatiOll of aa:idem), malpractice, product liability, homeowners)? Is noo-liability insurance available (For example: Premises medical, auto medical coverage, no-fault, homeowners premises)? If Yes, what is the name of the insurance company? What is the address? YES or NO YES or NO city? State? Zip? What was the date of the accidentfmjuIy? Who is listed as the insured? 26 , . '. ,'</;~',?~i(ir::\\i~,~iA<=~ENT(CQ~)' . ,; '~i"",.:",,,..,,,:.t'~''',''~''', ,:,,:q~,,:,~~~~~~.~~ SA. Docs the patieol feel someone else is responsible for the accidemrmjury? ICYes, What is the name of the patient's attorney or the rcspOllsible party's insurance company? What is the address? city? State? What is the name of the RlIpOIlSible insured party? ., . ,EMPLOYER GR,OUP BEALTp:,~ tt~1il;~::{::?,:',({,~~)::\:.~:~,'ri~>~::; :;:~:;'~1~F~". ";" 6. Is the patient covered by lID)' employee group health plan (EGHP). including the Federal Employee Health Benefits YES or NO f\J(J or Retirement Policies? UNo, dais quesUonnldre Is complete. UYES, CONTINUE. Zip? 'WORKING AGED ,~jE~;~;;~;6;:~~~;:,~::;';{<:;~',' 7. Is the patient 6S years or older? YES or NO C. ICYes, is the patient and/or spouse curreotly employed by an employee of20 or more employees? ICYes, is the patient covered by that employee group health plan (EGHP)? ICYes, what is the name of the EGHP? What is the address? City? State? Zip? IC the Beneficiary is no looger employed, please give a retirement date if possible: IC the is DO I I lease " e a retirement date if 'ble: ,:~>.:.~:r~~"::~~\~~.:~~i:~~}~7-:",~~::" " YES or NO YES or NO 100' ~~f~\fJ~:~:~' ~~:':~';"<i' DI$ABII.Jn' ~'~)~~~~W~;1~i~~~~~~~~0~fi:~r.~!~~~~~i~I~~~;ilf?i}~:~~ 8. Is the patient under the age 6S? ICYes, is the patient entitled to Medicare solely due to a disabili1y other than end stage renal disease? ICYes, is the patient or family member ClII1'eolly employed by an employee of 100 or more employees? ICYes, is the patient covered by that large group health plan (LGHP)? ICYes, what is the name of the LGHP? What is the address? YES or NO YES or NO YES or NO YES or NO City? State? Zip? . '}{i'%:;:;;:;;~2) :~;;:::ENl)S...AGE RENALD~~j:~~*r.~P0i:i:\~,f~W?S~'l{~";\~f~%~t~~';i:::;~. 9. Is the patient covered by lID)' EGHP through a curreut or former employer of lID)' size? Name of group health plan: Mailing address: City: State: YES or NO Zip: Policy #: Relatiooship to the patieot: Name of employer: Mailing address: City: State: Zip: Is the patient within the 30-m0nth coordination of benefits periods? What is the monthIyear of the first regular dialysis? (MMIDD/CCY) Has the patient had a kidney transplant? ICyes, date of transplant: (MMIDD/CCY) Note: ICthe 'ent is within the 30 month coordinatiOll ofbeoefits "od, the GHP should be y. Name of policyholder: Group identification #: YES or NO YES or NO . . DUAL ENTlTLEMElU:S~~,\':i%~;~Z~;h;.,~;? 1 O. Is the patient entitled to Medicare on the basis of either ESRD and age ofESRD and disability? Was the patient's initial eotitlemCllt to Medicare (including simultaneous entitlemCllt) based on ESRD? Docs the working aged or MSP disability provision apply (i.e. the GHP primary based 011 the age or disability entitlemCllt)? Note: I1Yes to the last question, the GHP remains primary for the 30 month COB perlod. -., ."" 27 Has 1bis pIIiad becD coofiDed to a bospital 01' skilled IIIIISiDg facility within the last 60 days? IIYes, CWllpIete the IoIIowtDc bd'ormatloD for adlltay: HCllIpitalorSNF: ~ "3', \ ",",,~\~SOu.:~ Address: By Whom Verified Disclwge Date: \\ \2" 10'2- Admission Date: ':.~~;f.;t\~"~~$~~~~,~:1~f;'~,~~::~.~~.~~~$~l":!t~~~:.~~~i~~~i~.~:.'~1~'~.~~~'C~~~~.~,~:~}l(~f>:Ji~~lf~~~f~t~~~~lre;~l~~~~ti~~~A:~~}:~~: . . 28 ATIACHMENT B-1 RESIDENT'S PERSONAL TRUST FUND AGREEMENT - (STANDARD) , . 30 HCR Manor Care RESIDENT'S PERSONAL TRUST FUND AGREEMENT The undersigned hereby agree as follows: 1. The Facility shall furnish the Resident with a written receipt for all expenditures and deposits regarding any of the Resident's funds deposited with the Facility. 2. A record of all transactions regarding the Resident's funds shall be maintained by the Facility in accordance with generally accepted accounting principles. 3. The Resident shall have access, at any time upon request, to the above record and shall receive an itemized quarterly statement of his /her account. 4. The Facility has a surety bond to guarantee the Resident's funds. 5. All Resident personal funds are kept in separate account(s) from the Facility operating accounts. 6. The Facility may keep Fifty and 00/100 Dollars ($50.00) or less in a non-interest bearing or petty cash fund for the Resident's account. Any money in excess of Fifty and 00/100 Dollars ($50.00) will be put in an interest-bearing account, with the interest to be credited to the Resident. If the Facility maintains an account with a bank on the resident's behalf, any service charges assessed by the bank will be deducted from the resident's personal tmst fund account. 7. The Resident acknowledges that, upon his/her discharge or death, the balance of his/her account will be promptly released to the private party or public agency required by law. 8. The Resident authorizes the Facility to distribute or return the Resident's money only to the Resident or the Resident's designated representative upon written request. 9. The Facility has no duty to invest the money in the Resident's account to earn income other than interest in a bank checking or similar account:or to accept a deposit which would cause the balance in the Resident's account to exceed applicable limits of federal or state law. 10. If the Resident receives Medicaid benefits, the Facility shall notify the Resident when the amount in his/her account reaches Two Hundred and 00/100 Dollars ($200.00) less than the social security income ("SSr') resource limit for one person and that, if the amount in the account, in addition to the value of the Resident's other nonexempt resources, reaches the SSI resource limit for one person, the Resident may lose eligibility for Medicaid or SSI. Date: \\\2..1 \ 0'Z... 'f.. '~.~ ~ ~,L Representative (Signatur Pc\- ~ Resident (Signature) Responsible Party (Signature) "^" ~ -\ \ '^"'e I Resident Name: Albright, Jean E ATTACHMENT B-2 31 RESIDENT PERSONAL FUNDS AUTHORIZA nON . . 32 HCR Manor Care RESIDENT PERSONAL FUNDS AUTHORIZATION INSTRUCTIONS FOR USE: Required on any resident eligible for Medicaid. Complete the one (1) appropriate section below, as follows: Part A - To be completed when resident requests receipt of the personal portion of their resource check or personal fund. Part B - To be completed when the resident's responsible party requests receipt of the resource check or personal fund. Part C - To be completed when the resident requests that the facility become the custodian of the personal portion of the resource check. or personal funds. Please ensure that in all cases, all signature approvals are obtained as indicated on the lower part of this form. PART A Date: I, Albriaht. Jean E , Patient No. 1310 as a resident of , request to receive monthly the personal portion of my resource check or personal funds in the amount of $ . By receipt of this money I hold hannless for any loss or further responsibility of this money. PART B Date: As the responsible party for Albriaht. Jean E, Resident No. 1310 at I am requesting to receive monthly, the personal portion of their resource check in the amount of $ . As responsible party, I realize a legal obligation to use these funds for the benefit of the patient and hold harmless for any further responsibility for this money. RULES AND REGULATIONS: 1. The facility will not loan funds to a resident whose balance falls to zero.2. The resident's signature is requi~ for all withdrawals. If a resident is unable to sign, two witnesses who do not receive or disperse resid'ent funds, petty cash or checks may sign for a resident. PART C Date: I, Albriaht. Jean E, Patient No. 1310 as a resident of designate on account. to be custodian of the personal portion of my resource cheek, or private funds deposited Wrtness (Required parts A, B, and C) Witness & Non-Employee Resident Signature, (Required parts A, B, and C) Responsible Party (Required parts A, B, or C, as appropriate) 1700 Market Street Camp Hill. PA 17011 Address (Required Parts A, Band C ) (Required parts A, B, and C) Administrator Approval I Resident Name: Albright, Jean E 33 / ATTACHMENT I CENTER SUPPLEMENT . BEDHOLD POLICY . SOCIAL SERVICE AGENCIES AND ADVOCACY GROUPS . OMBUDSMAN . INFORMATION ON AGENCIES, GROUPS AND GOVERNMENTAL AGENCIES/UNITS . MEDICAL DIRECTORS/PHYSICIANS . FILING A COMPLIANT FOR ABUSE, NEGLECT, MISTREATMENT OR MISAPPROPRIATION /' ATTACHMENTJRESIDENTHANDBOOK (ATTACHMENT K RESIDENTIPATIENT RIGHTS / ATTACHMENT L MEDICAREIMEDICAID INFORMATION / ATTACHMENT M-l REFUSAL OF LIFE-SUSTAINING TREATMENT POLICY /ATrACHMENT M-2 ADVANCED DIRECTIVES STATUS WORKSHEET 34 HeR MANOR CARE REFUSAL OF LIFE-SUSTAINING TREATMENT HCR Manor Care Centers are dedicated to supporting the resident to attain or maintain his or her highest level or physical, mental, and psychosocial well-being, in accordance with the resident's personal assessment, his or her individualized Plan ofeare, and the resident's wishes as to medical treatment. The resident's condition, however, may lead him or her to desire to limit the treatment provided by the Center, In such event, HCR Manor Care Centers will honor the requests of the resident to refuse life-prolonging treatment, provided that such refusals are done in accordance with HCR Manor Care's policies. These policies are designed to protect each resident's rights by following applicable state law governing who can legally consent to refuse treatment and requiring that the medical record reflect that any other applicable legal requirements have been satisfied. HCRMANOR CARE POLKY HCR MANOR CARE'S policy is to provide all treatment which is medically necessary to sustain the resident's life, unless a valid order to refuse such treatment is entered in the resident's medical record by his or her attending physician, in accordance with HCR Manor Care's Limited Treatment Policy or Policy on "Do Not Resuscitate Orders" ("DNR'" whichever may be applicable. Understanding Limited Treatment HCR Manor Care follows applicable federal and state laws governing the rights of a resident, whether competent or incompetent, to refuse unwanted medical treatment. An incompetent resident can direct care through an "advance directive" under applicable state law. A growing number of states also permit family members to act as '''surrogate decision makers" in the absence of an advance directive. Duly empowered legal guardians might also be permitted to refuse life-sustaining treatment under applicable state law. Because the laws of each state are unique, HCR Manor Care has a Limited Treatment Policy for each state. A summary of this State's laws on advance directives and surrogate decision making is contained in the admissions packet. The Limited Treatment Policy imposes procedural requirements for refusing life-sustaining medical treatment such as mechanical breathing, kidney dialysis, chemotherapy, blood transfusions, and artificial nutrition and hydration supplied intravenously or through gastric or nasogastric feeding tubes. Antibiotics might be refused if they are not needed to alleviate pain and the safety of others in the Center is not threatened. Whether or not to refuse treatment is a decision to be made by the resident and/or legal representative based upon the advice of the attending physician. HCR Manor Care recommends that the resident's decisions on the various treatment options be stated with as much specificity as possible. It is also recommended that the resident execute advance directives and, if a durable 35 power of attorney for health care is executed, that the resident discuss his or her wishes in detail with the designated person. Understanding CPR CPR is emergency medical procedure used in an attempt to restore circulation and respiration, which have ceased. The cessation of circulation and respiration is referred to as a cardiopulmonary arrest, It may take several minutes from the onset of a cardiopulmonary arrest to the point when the condition becomes irreversible. This time interval may represent a "window of opportunity" when CPR may be effective in restoring circulation and respiration. CPR consists of both basic and advanced life support procedures. Basic CPR involves rescue breathing and chest compressions. Rescue breathing is performed mouth-to-mouth or by using a special mask and bag. Chest compression, or external cardiac massage, is the compression of the chest at the lower part of the sternum with one's hands, using the weight of one's body for pressure. It is done to force the circulation of blood through vital organs. According to reputable industry studies, CPR has significant limitations. It may fail to restore circulation or respiration. Even if CPR results in the avoidance of death by the traditional definition, it may be too late to prevent brain damage. Additionally, circulation and respiration may be restored in time to preserve brain function, but administration of CPR may fracture ribs, lacerate organs, or result in other injuries. The administration of CPR is most likely to be successful when the resident is relatively young and does not have a debilitating condition. Center personnel will perform Basic CPR if a resident has a cardiopulmonary arrest unless a valid physician order has been entered in the resident's medical chart or CPR would be unsuccessful in restoring cardiac and respiratory function. Advanced CPR involves higher technology and will be administered only by paramedics called to the Center to administer' $uch procedures and to transport the resident to the hospital. 36 LIMITED TREATMENT POLICY - PENNSYLVANIA HCR Manor Care's policy is that all residents will be provided health care unless the attending physician enters a contrary order in the resident's medical record. The Center will act to maintain human life in accordance with accepted standards of ethical practice. Health care will be withheld only in accordance with the procedures set forth in HCR Manor Care's Limited Treatment Policy for Pennsylvania, which is summarized below. Competent Resident A competent resident can refuse medical treatment, including artificial nutrition and hydration, at any time. The attending physician must, however, record complete information in the resident's medical record to demonstrate that the decision to refuse treatment was made on the basis of informed consent. Incompetent Resident Pennsylvania law permits decisions to be made on behalf of an incompetent resident in several ways. 1. Declaration. If when competent, the resident has executed a living will (known in Pennsylvania as a "Declaration") in accordance with Pennsylvania law, then life-sustaining treatment can be withheld in accordance with the resident's instructions set forth in the declaration provided that the following requirements are met: a. The attending physician determines that the resident is incompetent; b. The procedure of treatment proposed to be withheld is consistent with the specific instructions, if any, of the resident set forth in the Declaration; c. The attending physician certifies in the medical record that the resident is either in a terminal condition or is in a state of permanent unconsciousness; and d, The attending physician arranges for the physical examination and confinnation of the terminal condition or state of permanent unconsciousness by a second physician. If the resident in his or her Declaration designated a surrogate to make decisions under these circumstances, then the consent of such surrogate will also be required. Artificial nutrition and hydration can only be withheld if all of the foregoing requirements have been met and the Declaration specifically provides for the withholding of artificial nutrition and hydration, e. Durable Power of Attorney and no Declaration. The Pennsylvania Durable Power of Attorney Act authorizes consent for medical treatment, but does not specifically authorize the withholding of life-sustaining treatment. Therefore; unless there is a court order providing otherwise, HeR Manor Care may not honor a durable power of attorney for health care. Any such document will be forwarded to the Legal Department for review. 37 2. Legal Guardian. Pennsylvania law may permit a legal guardian to authorize the withholding of life- sustaining treatment. The scope of the guardian's authority will be verified by the court documents which appointed the guardian. 3. Close Family Member and Penistent Vegetative State. If the resident did not executive a valid Declaration or Durable Power of Attorney, or if the resident does not have a legal guardian with authority to refuse life-sustaining treatment, then Pennsylvania law permits a family member who is sufficiently close to the resident to render a judgment on his or her behalf to refuse life-sustaining treatment tor a resident who is detennined by two qualified physicians to be in a "persistent vegetative state," provided that there is no dispute among family members, Additionally the attending physician must record complete information in the resident's medical record to demonstrate that the decision of the legal representative to refuse treatment was made on the basis of informed consent and that all other federal and state law requirements have been satisfied. , . 38 DO NOT RESUSCITATE POllCY CPR will be initiated without a specific physician's order or appropriate "Do Not Resuscitate Identification" when cardiac or respiratory arrest is recognized A specific instruction is necessary if CPR is not to be initiated, except in instances in which CPR will be unsuccessful in restoring cardiac and respiratory function. A valid DNR Order precludes the otherwise automatic initiation of CPR. A Do Not Resuscitate Order can be entered only by the resident's attending physician, after consent has been obtained from the legal decision maker and the required documentation has been inserted into the resident's medical record, in accordance with HCR Manor Care's Do Not Resuscitate policy. The legal decision maker for a competent resident is, of course, the resident. The medical record must reflect that an informed decision was made by the competent resident after discussion of all aspects of CPR with the attending physician. For an incompetent resident, entry of a Do Not Resuscitate order is appropriate only when the resident has either of the following physical conditions: (1) death is expected because ofa terminal condition, or (2) a condition exists in which CPR would not be expected to render substantial improvement in the ultimate outcome. Additionally, the legally recognized surrogate decision maker must consent in writing to the entry of the Do Not Resuscitate order, and the medical record must reflect that such person made an informed decision after discussion of all aspects of the order with the attending physician. The legally recognized surrogate decision makers for the purposes of the Do Not Resuscitate policy are the same as for a resident have no advance directives under the Limited Treatment Policy - Pennsylvania, described above. *** The above discussion will assist you in understanding HCR Manor Care's policies as to refusal of life-sustaining treatment. The Admissions Director will also explain HCR Manor Care's policies to the resident and the resident's legal representative at admission, and other staff members are available to answer any questions that may arise during the resident's stay at our Center. Copies of the ~n policies are available upon request. . 39 ** ~0'38~d l~101 ** HCR MANOR CARE ACKNOWLEDGMENT OF RECEIPT OF HCR MANOR CARE POLICIES ON L1MITED TREATMENT PRACTICES AND DO NOT RESUSCITATE ORDERS The Resident andlor Legal Representative hereby certify that he/she has received a copy ofHCR Manor Care's Policies on Limited Treatment Practices and Do Not Resuscitate Orders as part of the admissions packet. The Resident and/or Legal Representative further certify that he/she has read and understood the polici~ that helshe bas had an opportuDity to ask questions about the policies, and that hislher questions have been answered to bislher satisf8ction, The Resident and/or Legal Representative understand that limited treatment or "No CPR" orders can only be entered by the Resident's attending physician when other conditions of the policy have been satisfied, The Resident and/or Legal Representative understand that. prior to the entJy ofvalid limited treatment or No CPR orders by the attending physician, it is the policy of HeR Manor Care to provide all medically necessary health care services, including, when medically indicated, CPR The Resident and/or Legal Representative therefore acknowledge bislher responsibility to discuss the Resident's desires for limited treatment or No CPR orders with hisIher attending physician. SignatUre of Resident, if able to make medical decisions: Date: . . Signature of Resident's Legal Representative. if Resident is unable to make medical decisions: Date: 1\12.1 ( 0'2... '~'_.~ ,:,t)!: \. ~ ~L_ Date: IIIlZ!JO~ ~~ s,-\ee.\fler Center Representative 40 C:0/C:0'd SS~S6vC: 01 681C: ~~~ ~l~ llIH dW~-3~~J ~ON~W ~~ 10:11 v00C: 0C: d3S Advanced Directive Status Worksheet (To Be Used in Conjunction with HCR Manor Care Limited Treatment Policy) Admission Date: 11/27/02 O~mission ~ipt of HCR Manor Care "Refusal of Life-Sustaining Treatment" Handout _ Signed Acknowledgement of Receipt of HCR Manor Care Policy on LllDlted Treatment ~Practices and no cardiopulmonary resuscitation orders _ Provided with "State's Advanced Directive Forms - if desired (See Advanced Directives.) Responsible Party Name & Phone # . Resident (Competent) . Legal Guardian (Resident Incompetent) (Indicate if Guardian is over person. property, or both) Durable POAJHealth Care Proxy _ Legal RepresentativeJFamily None of the above Advanced Directives. Living WillIDeclaration _ Durable Power-of-Attomey for Health Care Other Note: If out of state advanced directive, an old advanced directive, if there are missing dates, signatures, or an improperly witness advanced directive, contact the Legal Department for assistance. No CPRlDNR Orders _ Physician's Order (Original order must be handwritten on physician's order sheet and placed on the chart-computer printout accepted thereafter.) Physician Documentation of Informed Consent in Progress Note _ Compliance with HCR Manor Care Policy in Section 3 of the Limited Treatment Policy Manual _ HCR Manor Care Release of Liability for the Limited Treatment Order (**Note) Limited Treatment Physician's Order (See above under "Physician's Order") Physician Documentation of Informed Consent in Progress Note Compliance with HCR Manor Care Policy in Section 2 of the Limited Treatment _ Policy Manual HCR Manor Care Release of Liability for the Limited Treatment Order (**Note) Organ Donor Receipt of Infonnation Related to Organ Donation Organ Donation Desired Date Received \\121162- Signature w5 * Note: Update advanced directive orders on a moothly basis. Verify that the resident or legal represeulative c:ooliDues to want the ordered treatment withheld/withdrawn or DNR status. For residents with no orders for DNR or I..imited Treatment, verify periodically and with a significant change in status or terminal diagnosis, whether they desire a No CPRlDNR or Limited Treatment Order. "Note: After the physician bas obtained informed consent, obtain the signature oCthe resident or legal rcprcsentative(s) on the HCR Manor Care Release of Liability form unless the situation makes it impossible to do so. Try faxing. mailing or reading fonn (on the phone with witnessing) to the legal representative in each child sign the release form. I Resident Name: Albright, Jean E Medical Record #: 1310 41 ATIACHMENTN PRIVACY ACT NOTIFICA nON . . 42 lIeR lIallo/' ( lI/'t' PRIVACY ACT STATEMENT-HEALTH CARE RECORDS THIS FORM PROVIDES YOU THE ADVICE REOUIRED BY THE PRIVACY ACT OF 1974. THIS FORM IS NOT A CONSENT TO RELEASE OR USE HEALTH CARE INFORMATION PERTAINING TO YOU. 1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL SECURITY NUMBER (SSN) Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act, Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive, accurate, standardized, and reproducible assessments of each resident's functional capacity and health status. As of June 22, 1998 all skilled nursing and nursing facilities are required to establish a database of resident assessment information and to electronically transmit this information to the State. The State is then required to transmit the data to the federal Central Office Minimum Data Set (MDS) repository of the Health Care Financing Administration. These data are protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records. 2. PRINCIPAL PURPOSES FOR WIllCH INFORMATION IS INTENDED TO BE USED The information will be used to track changes in health and functional status over time for purposes of evaluating and improving the quality of care provided by nursing homes that participate in Medicare or Medicaid. Submission of MDS information may also be necessary for the nursing homes to receive reimbursement for Medicare services. 3. ROUTINE USES The primary use of this information is to aid in the administration of the survey and certification of MedicarelMedicaid long term care facilities and to improve the effectiveness and quality of care given in those facilities. This system will also support regulatory, reimbursement, policy, and research functions, This system will collect the minimum amount of personal data needed to accomplish its stated purpose. 43 The information collected will be entered into the Long Term Care Minimum Data Set (LTC MDS) system of records, System No. 09-70-1516. Information from this system may be disclosed, under specific circumstances, to: (1) a congressional office from the record of an individual in response to an inquiry from the congressional made at the request of that individual; (2) the Federal Bureau of Census; (3) the Federal Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease of disability, or the restoration of health; (5) contractors working for HCF A to carry out MedicarelMedicaid functions, collating or analyZing data, or to detect fraud or abuse; (6) an agency of a State government for purposes of determining, evaluating and/or assessing overall or aggregate cost, effectiveness, and/or quality of health care services provided in the State; (7) another Federal agency to fulfill a requirement of a Federal statute that implements a health benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII functions, (9) another entity that makes payment for or oversees administration of health care services for preventing fraud or abuse under specific conditions. 4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON INDIVIDUAL OF NOT PROVIDING INFORMATION For nursing home residents residing in a certified MedicareIMedicaid nursing facility the requested information is mandatory because of the need to assess the effectiveness and quality of care given in certified facilities and to assess the appropriateness of provided services. If a nursing home does not submit the required data it cannot be reimbursed for any MedicareIMedicaid services. 44 ATTACHMENT 0 INVENTORY OF PERSONAL EFFECTS . . 45 ATTACHMENT P ASM FORM 47 III' illon \,'/'1 i" \ \/11I1IIg,'/lI<'lIf. /11<, )fS9J. We are pleased that you will allow Ancillary Services Management, Inc. ("ASMJI) to serve your Medicare Part B suPPIYileiiJs. JrSM Is-a -national Medicare Part B provider and has an agreement with this facility to provide certain medical products for eligible nursing home residents. Some of the products ASM supplies include nutritional supplies for tube feeding, foley catheters for urological patients, surgical dressing supplies, as well as ostomy and tracheostomy supplies for those patients who require them. The Health Care Financing Administration, which is the governmental agency responsible for the Medicare program, requires providers like us to obtain authorization to supply, bill and receive payments on behaff of the beneficiary from the beneficiary and/or responsible party. In the event you need the supplies noted above, we can supply and bill Medicare Part B on your behaff. Please sign and date below, authorizing ASM to bill Medicare Part B on behaff of the beneficiary. Once again, thank you for your business. ff you have any questions, please feel free to contact ASM at (419) 252-6000. Sincerely, Frank A. Jannazo Director of Operations ................................................................................................. SELECTION OF ASM Patient Name: Albriaht Jean Last First Social Security #: 187-05-0089 E Middle Facility: HCR ManorCare-Camo Hill The resident and/or legal representative hereby selects ASM to provide Medicare Part B supplies ordered by the resident's attending physician. The resident and/or legal representative hereby request that Medicare benefits be paid directly to ASM for any medical supplies provided to the resident which are covered under Medicare Part B and hereby authorize .ASM to bill and collect for such medical supplies directly from Medicare or other third party payor. I further authorize any holder of medical information about me to release to the third party payor(s) and its agents any information needed to determine these benefits. Date Resident Signature 1<.. ~G". · ~ U~ Signature of Legal ep entatlve 48 ATTESTATION OF ADMISSION AGREEMENT AND ATTACHMENT I ~v..'l '" <s~ff\.e..r- , on behalf of the Center HCR ManorCare-Camp Hill Name Center hereby certify, as indicated by my initials set forth below, that I have provided the Resident and/or Legal Representative of Albright. Jean E with the Resident Name Admission Agreement and each of the attachments listed below. I also acknowledge that I have gone over each of the attachments with the Resident and/or Legal Representative, that the Resident and/or Legal Representative have had the opportunity to ask questions and have had all of their questions answered satisfactorily. The Resident and/or Legal Representative have signed each of the required documents in my presence indicating receipt and understanding. ~'. Authorization for Release or Review of Medical Information. See Attachment C. :;-J;>; Authorization for Payment of Benefits. See Attachment D. .c. Social Security Administration Appointment. See Attachment E. ~d. SNF Medicare Determination Notice. See Attachment F. // e. Medicare Secondary Payor Questionnaire, See Attachment G, ~f At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in (;ompliance with the laws and regulations relating to the Center's management of such funds, A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachment H-l and H-:2. /' g. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I. ~ h. Social Service Agencies and Advocacy Groups addresses and phone numbers. " See Attachment I (Center Supplement). /i. Name, address and phone number of Ombudsman. See Attachment I (Center // Supplement). 1. The lociltion in the Center where the names, addresses and telephone numbers of state cIlent advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center / Supplement). _ k. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center / Supplement). 1. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. See Attachment I (Center /' Supplement). / m. The Resident Handbook. See Attachment J, / n. Resident/Patient Rights. See Attachment K. ~ o. MedicarelMedicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. 1. Copy of Medicare Card for file. 49 2. Copy of Medicaid Card for file, p. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR jManor Care's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary ofits laws governing the Resident's right to direct his/her medical . treatment. See Attachment M-I and M-2. / q. Privacy Act Notification. See Attachment N. r. Inventory sheet and/or policy of personal items. See Attachment O. "./ s. ASM Form. See Attachment P. t. Copy of Social Security Card for file, u. Copy of all insurance cards for file. v. Copy of Prescription Card for file, Note: pleas~: copy both sides of card. ..-w.Copy of Living Will for file. . J x. Copy of Health Care and Financial Power of Attorney for file. y. Copy of Guardianship or Health Care Surrogate papers for file. ,2: Complete Admitting and Discharge Record (Face Sheet). ./ aa, Verification of Medicare Coverage through lllQA bb. Se:e Attachment Q. cc, See Attachment R. dd. S~:e Attachment S. ee. Sl~ Attachment T. if Sc~e Attachment U. The Admission process for the above named Resident was completed on the date( s) set forth below. ~"" '^- CS---to e. ffi...e \ Name ,\\"Z-1.IOL . Date 50 NOV 13 2002 12:02 FR MRNOR CRRE 717 737 7389 TO 6655251 P.01/04 HCR.ManorCare APPLICATION FOR RESI:DENCY To apply for admission to our Nursing CtDter, please complete the foUDwiDg questionnaire, sign, add return it to tbe Admis.~iODs Office. This application will become a. part oftbe "Admission Agreement" and should be completed in itJ entirety. All information will be held irl confidence. The complete medical history lIDd physical examination resulu will be recorded 00 a.Dother document. Date: J J -I<J-()J.- Name of Prospective ResidentIPatient: :leA 10 Date of Birth: 05- 03- Jb Address: &;;lD /-.1;tl1 ~ R.cJ... APT Fia(, (line 2) CAM,o __If ~ J 701/ Marital Status: Married Widowed U Married or Widowed, Name of Spouse Social Security No: \ ~ ~ - as - a~C) BMO/Insurance: Provider , C. \-\_ _ ID No: ~~~O~,,'\':\ Group No: Insurance is: Primary' Secondary Other Insurance: Provider ID No: Group No: Insurance is: Primary Secondary E. A I bRltJ~T Sex: F XM_ . Telell,hone No.: 7 J 1- 7'.'i-J.j 197 Single ~ Medican No: Policy No. Co-insurance Policy No. Co-insurance Name ofInquirer: De60~{H./ J. "JO H-bJSq,v Address: ;),6 SAUo Au e.. (line 2) J...A,uc..~-Ie~ P,4 / 7b 0 I Other persons to cQntact in case of emergency: Name: Address: (line 2) Relationship: N I e.C.-€..- Telep,hone No.: 117-SIo9-J9Y? Othe:r Phone No.:117-lD~tJ-~lIOO ,Relationship: TeleI,hone No: Other Phone No.: tYl A NO IL <AIL'€...- _Nursing Center? N ewspaperlMagazine ~ S"i) lL.f-~ tZd146 TelevisionIRadio_ Yellow Pages Health Dept. Seminar/Event Assisted Living err. How did you hear about Personal Referral Hospital l-feA Ifl1 Physicia.n Other Professiona.l MailingIBrochure Other Nursing Ctr. Have you visited any other Nursing Centers or Assisted Living facilities? If yes, which ones? tV 0 txfLIBI7 .e. 1 NOV-13-2002 11:53 717 737 7389 99% P.01 NOU 13 2002 12:02 FR MRNOR C~RE 717 737 7389 TO 6655251 P.02/04 PERSONALfMEDICAL DATA Mother's Maiden Name: Father'sName: u.JAI.J.eL ~,be..e..S~.0 Place of Birth: City ~CA-S~ R- County ~S~ tL State P A- Church Preference (Optional): Preferred Ambulance Company (Optional): Name City Diagnosis: Current Primary Physician: Dp-. P€../J..NPt Physician to Collow at Facility: T.~ephone No.: Telephone No.: Tell us about the ResidentIPatient: (please check all that apply) _Mentally alert _Ambulatory _,Confined to bed . ~Slightly forgetful ~~>Walks with assistance ~:Eats without ~ssistance~J:;Q) _Confused _Continent ~e..~ .Requires assistance with u. ~ ilS. Incontinent eating Admission desired on: Resident/patient currently at: S, l-l.f..8:l:fh & t.t...+h.. If hospital: Date admitted Admiitted from Where has the resident/patient lived in the last 60 days?:. H-o Wl e. - 01 bP\rL. sP ~ l+eA- sa lA: FINANCIAL INFORMATION The facility requires tbat a source of paymcDt by identified to pay fc)r the ResideatIPatient's care. A person, other than the resident, may wish to,be fiDucially respoolsible for the cost ofthe care ("'guarantor"). The facility d~5 not require a "guarantor". Name of the "Gu~rantor": ~ddress: 1 Telephone No.: Work No.: Other No.: (This person(s) must also complete the cCGuarantor" info'rmation and sign the application.) Has a trust fund been established for the ResidentJPatient?: Yes No Has a Power of Attorney been conferred on the. person(s) to be financially responsible, or on the person(s) who will act on behalf of the r'esident ("Responsible Party")?: _Yes _No Ifyes~ please provide a copy. Has a legal gundian been appointed by a court? _Y.es _No If yes, please provide a copy. Has a Burial Trust been established?: _Yes _No If yes, with whom?: If no, who is the preferred funeral service for the Resident/Patient's family?: 2 NOU-13-2002 11:53 717 737 7389 98% P.02 NDV 13 2002 12:03 FR MRNDR CRRE 717 737 7389 TO 6655251 P.03/04 To process your application, tbe following infonnation is required. The information supplied is confidential and allolVs us to assist you ill your long-tenn planning. The financial d:ata should be tb:at of the ResidentlPatient and or the Guarllltor. All income and amouDts listc'd. whetber listed uDder the Resident or Guarantor column. must either be OWlled by the Resident or in fact be a\'lilable to the Resident to pay for the Resident's Stay at the facility. Your coopentioll is appreciated in order to ~pedite admission. Please Dote that it is not mandated that a ResideDt bave a GuatllDtor, only that a source of payment be identified. nuS. any person who agrees to be a GU21'211tor is doing so voluntarily. ASSETS: RESIDENT GUARANTOR (if any) Cash S $ Checking l \ ~~(\ -\) () Savings \\~~<L Money-Market '{\c~CL- Certificates of Deposit ~ C\ ~e..- Securities (StockslBonds) '^ f\ (\.Q Trust \'\c~ Annuities (if not yet paying "a~<2-- IRA monthly) MONTHLY INCOME: Salary $ $ Social Security \ s.G~- ~~ Pensions/Annuities (if not above) Y\ (') t'\ ~ IRA (if not above) \{\ C'. ~<L- InterestIDividend Income \c\ l'\ ~~ - Rental Income \'\. C"l t\~ _ Trust V\ Q (\~ Investments/Other Y\ 0 ",C- Long-Term Care Insur2nce '<\ 0 he..- NA . . REAL ESTATE: (descriptioDnocanon)' Property: ,.J 0 N e.., Name on Deed/Title Property: NO~e Name on Deed/l'itle OTHER ASSETS: Cash Value Life Insurance \'\D~ Vested Pension Benefits \"'\D\"Ct _ Business Interests \\h t\~ .- Automobiles Other \\~~o Total Assets: J NDV-13-2002 11:53 717 737 7389 9:3% P.12l3 NOV 13 2002 12:03 FR MRNOR CRRE 717 737 7389 TO 6555251 P.04/04 " '. , LIABILITIES: Home Mortgage Credit Cards/Charge Accounts Loans Other Debts Taxes Owed s RESIDENT \(\o~ GUARANTOR s '{\. () ~<L- '^ ~ (\~ \l\b~ .... Total Liabilities: NET WORTH: (assets - liabilities) $ s PLEASE SIGN BELOW: I hereby warrant and represent that the informatiod pro~ided is 2ttlJrate and complete. I understand that the nursing facility will rely UpOD the accuracy and completenesl of tbe above fiDanciaJ information in making an admission decision. I also uDderstud that if any of the information is Dot accurate or not complete, tbe Facility will have detrimentally relied upon the above financial information and will suffer finJnciaJ loss :.Ind bann. The asxts listed are iD ract aVlU1able to the Resident to pay for the Resident's care. \J'f j\ ,,-I ~~s \2- <0 -0"2- Resident's or Responsible Party's Signature Dim Guarantor's Signature: . . ['ate Reviewed by: - nate /L/ '/UL I _ IrJ)J>/o2 I).tt I I 4 NOV-13-2002 11:54 717 737 7389 %% ** TOTRL PRGE.04 ** P.04 '. 11/16/" ~EsIOEUT LEDSER AS OF DATE OF FIRST ACTIVITY PAGE ,/(,*R 56 ) RESIDENT RESIDENT RESIOEn 6/L -- ACCOUNTS RECEIVABLE -- NUXm TYPE MA~E DATE QTY ACCOUH CHARGES CREDITS BALANCE 1318 mrcm ALBRIGHT r Jm E 83/29103 ADA em RATE: UO ROO~ 311 -8 LEVEl 3 1L/lo/03 DIS PRIV PORT: 1545.78 .. PRl V ATE . JUl 03 BAt fWD -LN- -30- -H- -91- -llQ +- 3238." 1631. II 1650.80 53U8 735 3.6 B PAY~ENT CHECK i 2714 B7/11/03 112U8mU 534.58 PAY~E"T CHECl f 2714 07/31/03 1l2lUI2GU lGS o.a 0 PAY"ENT CHECr. t 2714 01/31/03 11210002001 815032 PAY~ENT CHECK. 435 07/31/03 11218U2010 8i5.68 PAY~ENT CHECK + 435 . 87/31/13 11mmm 1184,32 11m CABLE RENTAL B7 /01m 59158m3H 12.90 REV LAST "0 PP . 81/81/83 13211eeme mUI PRIVAH PORT1O~ 07/81/03 -- '7/23/13 2J l6Ii U 0 ADV PVT PORTION Ds/elm 1321100BOOO 16~'.'B ..E~DING BALANCE 3605.58 "PRIVATE - AUG .3 BAl fWD -l"- -n- -60- -9B- -lze.- 3212." 453.68 mus 11m CABLE REnAL 08/31103 S915SH1m 1.2." RtV LAST AD PP tatu/03 132wum 1699.10 PRlvm PORTION e~/Ol/03 -- 88/31/03 31 mo.u ADV PVT PORTION 89/11/03 1321190~10~ 16~O.ee "EMOINS BALANCE $211.68 uPRlVATE - m 13 aAL FWD -LM- -31- -60- -91- -120.' 321z.n 1612.11 m.68 5m.68 PAfNf<<T CKEC( t 2115 69/03/03 112118OZtoe 45$.68 PAYNENT CHECK t 2715 89/13/A3 1121Ut2901 546,32 PAYMENT CHECK t 271~ 89/23/03 1121tmm 1165.08 PAY~ENT CMECK 1 2115 89123/.3 U2lJ88Zm 151UI PAYRENT CHECK t 2110 89/23/13 11216102881 2322.32 11ue BEAUTY AND BARBER 89/01/63 SmSUI32B 12.66 11m BEAUTY ~"U 8ARBER 89/22Je3 59158181321 Z5.10 11m CABlE RENTAl Og/H!13 5915S401308 12. ea REV lAST "0 PP 09/11/13 13211 lUlU 1583.81 PRIVATE PORTION 89/0l{.3 -- 19/23/13 23 Im.eo AOV PVT PORTION 10/U/f3 13211030.81 1668.'1 .tENDIM6 8ALANCE 913.6 S "PRIVATe - on 83 SA l HID -LN- -31- -5~- -90- -128+- m.68 H3.6~ 11m CABlE RENTAL II/Hi03 59158411380 12.18 REV LAST NO PP li/Il/D3 13211UUOI 1m." PRIVATE PORTION 19/11/03 -- 10/31/13 31 \m.ee AOV PVT PDRT[O~ 11 /61 /t3 \321180'011 1~81.'1 eXHIBIT "D" 0V1.0'd SSl.S6VG 01 681G l.~l. 1.11. llIH dW~J-3~~J ~ON~W ~~ vl:vl v00G 11 8n~ i: '7/16/14 RESIOENT LEDGER AS OF DATf OF FIRST ACTIVITY pm ../t'l1RS6) RESIDEMT RESIDENT RESIDENT G /l -. ACCOUNTS RECEIVA8LE "mER TYPE mE . DATE OTY ACCOUNT tWaES CREDITS SAlANCE 1311 UOlCAID ALBRIGHT. JEAN E '3/29/93 AD~ tm RATE: 3.19 ROOM 311 -8 LEVEL 3 11/16/03 O!S PRIV PORT: 15~5.78 uPRIVATE - OCT 83 (CO~TJ ROlL moITS (BLIND) 99/30 m l441mmo 6~16.32 ROLL moITS (8lINO) ~9/H/03 1441l050m 696.32 .rENQIN6 BALANCE 2515.6 8 "PRIVATE - ROV H 8At HID ~LN- -)9- -60- -91- -IH+- 2515.68 2515,58 PAYNENT SOt SEe CHECK' 11/11/03 I121UmU l~SI.ot REV LAST .0 PP !1/U/9J 13211mm HU.U PRIVATE PORTION 11/81/33.-- 11/15/03 16 16110.00 ttENOI~6 BALA~CE 1928.68 "PRIVATE . DEe IJ B A L FWO -LA- -36- -60- -91- -129.' 113.11 915.68 112 8.6 8 .tENDIftG 8ALA~CE 1128.68 "PRIVATE - JAM U au fWO -L"- -38- -68- -90- -120+- I 113.99 915.6 8 102 B.6 8 REV PRIV PORT 86/31/03 14411050m 1680.08 PRIVATE PORTION i6/31/83 14411158tOl 15~5.88 INSURANCE PRENIUN OS/31/13 3343mm8 186.6S REV mv PORT 19/31/13 144111SUII 1601.11 PRIVATE PORTION 09/30/03 144110580.. 1545.78 INSURA~CE PRE"IUM 89/30/03 3Hmmu 186.65 REV ?RIV PORT 10/31/03 1441l0meo 1680.00 PRIVATE pomo~ 11/31/13 1.~11f5'4" 1545.70 INSURANCE PRENIUN . . H/31/03 3343We5U 186.65 REV PRIV PORT llmm lHlusem 1618.93 PRIVATE PORTION 11/38/83 14411958118 1545.70 IHSURA,CE PRE~lU. 11/38/83 33mmsu 186,65 ttENDING BAlANCE 64.18 .'PRIVATE -mOl BH FUD AlM- -JQ- -60- -91~ -i2h- 127.95A 67U3 482.50- 64.18 REY PRIV PORT 03/31/13 1441usuoe 433.68 ROO~ CH6 3/29-3/31 83/31/13 5l3S3mm !,H. DO REV mv PORT 94/30/93 1441H5Un 1000.90 PHARWY LEGm 04/38/83 54551231221 ~,15. 59 PHAR~ NONlEGW 04/30/03 ,4951301221 10.13 LA8 SERVICeS 04/30/03 561519U2ze 6UI nW/ENTRl SHV U/38/03 5H5150l221 H2. S8 TOTAL IftCONT FEE 04{38/03 55151mm 9t.9~ LAS SERVICES 04/3f/03 56151mm H.se LAB SERVICES 8w/n/13 5615mme 42. ee WOUND TX 84/30/83 S4151Sa1229 86. eo PHARMACY IV DRUGS 84/31/03 543SHOl228 m.21 0V80'd SS~S5vc 01 581c ~~~ ~1~ llIH dW~J-3~~J ~ON~W ~~ Sl:v1 v00c 11 8n~ .. ;: t7/16/04 RfSIDE~T lEDGER AS OF OATE Of FIRST ACTIVITY PAGE 3 ...: tAR56) RESIDENT RESIOENT RESIDENT S/l -- ACCOUNTS RECEIVABLE -- "UNSER rYPf NA~E om QTY moun CHAR6ES CREDITS SALAm .. 1311 NEOIcm ALBRIGHT. J EAt! E 83/H/03 m cnn RATE: 8.80 R ODA 311 -8 LEVH3 11/16/03 DIS PRIV PORT: 1545.1. uPRIVATE . H8 14 (CONI) MEDICAL SUPPLIES 04/36/03 54151501216 IllS. 8 6 lAB SERVICES 84/3t/13 56151981 m 51.U RM CHG 4/1-4/38/'3 04/31/03 51351011220 59~0.1~ REV R~ WID 05/31/93 51551il1321 18~5.21 PHARUCY LEGEND 8S/31}03 54551mm HU1 INCDNT fEE 85/31}13 561SlfiDlm 9U3 PHARnACY Non lEnD 15/31/13 54951301226 3.88 URINARY DRAIN BAG 05/31/33 541515&1220 8.77 OYNAPU1SE SED RENTAL 05/31/33 55352931221 m.e~ ROO~ CHARGE 5/1-5/31 9S/3!/03 S13SI~01121 6448.01 REV PRIV PORT OS/31/03 144110SUU 1691.10 REV Rn 11/0 15[31H3 51551mm m6.21 PHAR~m lEGEND 86/30/83 &46612012,1 119.29 TOTAL IffCO~T fEE 9~/33/03 561518WH 99.91 APK 06/30/03 563WOl 22. m.u R~ CHG 5/1-6/31/33 06/19/'3 51350102321 6240.11 REI' PRIV PORT 90/31/03 1441Usuee 169ue pmmy LESEND OJ m/e3 $46S12Um m.68 PHARAACY lEGEND 01/31/03 SHS1H1221 609.0S PHAR~ACY NONLE6END 01/3IfI3 ~H51mm 24.61 /OT~L J~CONT FEE 17/31/03 56151mm 9U8 m 01131/13 SS3 52911 m 3iue RM CKG 7/1-7/23/03 81 /31/13 51358811228 4784.90 ~~ CHG 7/2&-7/31/~3 17/31/03 51353801228 la55.38 REV PRIV PORT 01/31/83 14411mm 100UI "fNDING BALANCE 22831.48 uPRlVATE - lIAR 84 8A! fWO -l"- -31- -60- -90- -12e+- 121.9S- 22959.43 221131.43 ROLL CREDIT (BlIND) 83/31/H 14411l58m W.9S ROLL emIT (BlUO) 13/31fD4 lHlllsun 127.95 "ENOING 8AlA<<eE 22831.4 8 '.PRIVATE . APR t4 BAt fWD -LM- -34- -63- -90- -12ft- 2283U8 nl3l.48 .tENDING 8ALANCE m31.H uPRIVATE - m .. BAL fWD -IN- -31- -60- -go- -lH+- 22831.48 W31.4& MA O~f PArmi 8B/H/03 &S152Ulla 135US MA OME PAVUNT 0913'/83 S61smlllO lm.o5 NA DAf W~EHT lOf31/83 HlSW1W 13S9.05 KA onE pmm It /38 /93 ~SlS218l129 135 9.0 5 "[MDIN6 BALANCE 11395.28 uPRIVATE - JUM 14 BAl FWO -LN- -31- -00- -91- -121+- 17m.28 17395.28 0V60 . d SSl.S617C 01 681c l.r.l. 1.11. llIH dWI:::O-3e:itlJ ~ONtlW H:l S1 :171 1700c 11 9ntl ** 0~'3~~d l~101 ** tl/16/84 ~... ttRS6) RESIDEKT RESIOE~T mm mE REsrOENT HUE 1310 MEOItAln ALBRIGHT, JEAn E RDD~ 311 -8 LEVEL 3 ..PRIvATE - JUl.' (COKT) i.eNDING 8Al~HCE 0V12H'd RESIOENT lEDGER AS OF DATE OF FIRST ACTIvITY PAGE G/l -- ACCOU~TS RECEIVABLE -- DATE QTY Aceou~T CHARGES CREOlTS 8~L~NCE r> 0}/29J~l AOr. CMTR RATE: I.ea lL/16/03 CIS PRIV PORT; 1515.70 17395.28 i SS~S6VG 01 68~G ~~~ ~~~ llIH d~J-3~~J ~ON~W ~~ St:vt v00G t~ ~n~ CERTIFICATE OF SERVICE I hereby certify that on November 3, 2004, I, David A. Baric, Esquire of O'Brien, Baric & Scherer, did serve a copy of the Amended Complaint, by first class U.S. mail, postage prepaid, to the party listed below, as follows: Roxanne C. Gamer, Esquire Law Offices of Russell, Krafft & Gruber, LLP Hempfield Center, Suite 300 930 Red Rose Court Lancaster, Pennsylvania 17601 ~p~ David A. Baric, Esquire .. C) ,...., 0 ...:.::J C = "'Tl ..c:- ,. :7 ,",ll~ ~~ C) Cll.'Jd .....:,: -r.l Fn -~ I..... I r ","6 , (J) ;:~, ,:,')c i' '-" "i -r, ..-,.... ,,' )':''''- s~j ~s =,c .Cc ,- u 25 t2"n --,j -.+1 i~:j -< w -< II " . i- HCR MANORCARE, INC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004- 04776 CIVIL TERM DEBORAH 1. JOHNSON, a/k/a DEBRA J. JOHNSON, Defendant. CIVIL ACTION-LAW PRAECIPE TO ATTACH SUBSTITUTE VERIFICATION Please attach the following Substitute Verification to the Amended Complaint filed in this matter on November 3,2004. Respectfully submitted, O'B~EN' B;: ~RER David A. Baric, Esquire J.D. #44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 Date I '/ 1~1/.. dab.dir/mano rea re/alb right/su bstituteverifiea tion. pra VERIFICATION I, Helen Moloney, verify that the statements made in the foregoing Amended Complaint are true and correct to the best of my knowledge, information and belief. I hereby ratify the verification previously supplied by my attorney, David A. Baric, Esquire and execute this verification as a substituted verification. I understand that false statements herein are made subjectto the penalties of 18 Pa.C.S. S4904 relating to unsworn falsifications to authorities. Date: \\-~.CJ'1 ~/h1!__ Helen Moloney Administrator II . ,11 I CERTIFICATE OF SERVICE I hereby certify that on November 10,2004, I, David A. Baric, Esquire of O'Brien, Baric & Scherer, did serve a copy of the Praecipe To Attach Substitute Verification, by first class U.S. mail, postage prepaid, to the party listed below, as follows: Roxanne C. Gamer, Esquire Law Offices of Russell, Krafft & Gruber, LLP Hempfield Center, Suite 300 930 Red Rose Court Lancaster, Pennsylvania 17601 ~/c David A. Baric, Esquire -" (-;. 1"-.) ( (::-:':) 0 c:..., .JC'" -n 'T~ '" ~'~~ '", -~l " ," rll " .......:,: --' ,-" -, rn -, Ul 0 -- ). -0 ~-::) ,1"/ _;J -j-"': I J' C-~) r::) )irJ -':i :--1 -..: ~\_~ UI Gary G. Krafft, Esquire Attorney LD. No.: 19351 Russell, Krafft & Gruber, LLP Hempfield Center, Suite 300 930 Red Rose Court Lancaster, P A 17601 Telephone No.: (717) 293-9293 Facsimile No.: (717) 293-5130 G:\Userslajo\RCG\Litigation'Johnson, Deborah Answer.wpd: 10/20/04 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC. Plaintiff Docket No. 2004-4776 v. DEBORAH J. JOHNSON a/kIa DEBRA J. JOHNSON Defendant DEFENDANT'S ANSWER TO PLAINTIFF'S AM:ENDED COMPLAINT 1. Admitted upon information and belief. 2. Admitted. 3. Admitted. 4. Admitted upon information and belief. 5. Admitted in part, denied in part. It is admitted that Jean E. Albright was in need of admission into a nursing care facility. It is specifically denied that on November 27,2002, Jean E. Albright sought admission to the ManorCare facility as Jean E. Albright was incapacitated and unable to do so on her own behalf. 6. Admitted in part, denied in part. It is admitted that Deborah J. Johnson met with ManorCare employees at the ManorCare Facility. It is also admitted that Deborah J. Johnson signed an Admission Agreement as the Legal Representative for Jean E. Albright, signing on behalf ofJean E. Albright. 7. Admitted. 8. Admitted in part, denied in part. It is specifically denied that Jean E. Albright completed an Application of Residency on November 19,2002" as she was physically incapable of doing so. It is admitted that her mark appears at on the signature line, however it is specifically denied that the information in the Application for Residency was provided or reviewed by Jean E. Albright. 9. Denied. It is specifically denied that the information in the Application for Residency was provided or reviewed by Jean E. Albright. Therefore it is specifically denied that Jean E. Albright represented she was receiving Social Security income of $ 1,500.00 per month as of November 2002. 10. Denied. It is specifically denied that Deborah 1. Johnson received Jean E. Albright's Social Security benefits from November 27, 2002, through November 16, 2003. It is further denied that the alleged monies received by Deborah 1. Johnson totaled in excess of$ 18,000.00. 11. Denied. It is specifically denied that upon admission to the facility Jean E. Albright made application for medical assistance to pay a portion of her monthly costs of care at the facility. By way of further answer Jean E. Albright was not physically capable of making said application. 12. Denied. It is specifically denied that Deborah J. Johnson failed and refused to provide information requested by the Department of Public Welfare, COWlty Assistance Office necessary to make a determination of benefit eligibility. By way of further answer, Deborah 1. Johnson provided all necessary information in a timely fashion. 13. Denied. It is specifically denied that the County Assistance Office denied benefits to Jean E. Albright as a consequence of Deborah 1. Johnson's refusal to provide the necessary information. By way of further answer, Deborah J. Johnson provided all necessary information in a timely fashion. Further, Deborah J. Johnson is without information sufficient to admit or deny the reasons for the denial of Jean E. Albright's Department of Public Welfare benefits. 14. Admitted. It is admitted that Jean E. Albright was deemed eligible for medical assistance benefits effective August 1, 2003. 15. Denied. It is specifically denied that the Department of Public Welfare would not make benefits retroactive to the date of admission based upon Deborah J. Johnson's failure to provide requested information. By way of further answer, Deborah J. Johnson provided all necessary information in a timely fashion. Further, Deborah 1. Johnson is without information sufficient to admit or deny the reasons the Department of Public Welfare rt~fused to make Jean E. Albright's medical assistance benefits retroactive to the date of admission. 16. Denied. Denied inasmuch as the Admission Agreement as attached is a document which speaks for itself. 17. Denied. After reasonable investigation, Deborah J. Johnson is without knowledge or information sufficient to form a belief as to the truth of the averments of paragraph 17. COUNT I - BREACH OF CONTRACT 18. Defendant hereby incorporates by reference her answers to paragraphs 1 through 17 as though set forth at length herein. 19. Denied. After reasonable investigation, Deborah J. Johnson is without knowledge or information sufficient to form a belief as to the truth of the averments of paragraph 19. 20. Denied. Denied inasmuch as the Admission Agrl~ement as attached is a document which speaks for itself. 22. Denied. After reasonable investigation, Deborah J. Johnson is without knowledge or information sufficient to form a belief as to the truth of the averments of paragraph 22. 23. Denied. It is specifically denied that Deborah J. Johnson has breached the Admission Agreement by failing and refusing to pay for the services and care provided from the assets and income of Jean E. Albright. By way of further answer, Deborah J. Johnson was not a party to the Admission Agreement. 24. Denied. After reasonable investigation, Deborah J. Johnson is without knowledge or information sufficient to form a belief as to the truth of the averments of paragraph 24. WHEREFORE, Defendant, Deborah J. Johnson, respectfully requests this Honorable Court find in her favor and against Plaintiff. COUNT 11- MONEY HAD AN D RECEIVED 25. Defendant hereby incorporates by reference her answers to paragraphs 1 through 24 as though set forth at length herein. 26. Denied. It is specifically denied that Deborah J. Johnson received $ 18,000.00, in social security benefits paid to Jean E. Albright. By way offurther answer, any monies received by Deborah 1. Johnson on behalf of Jean E. Albright were used for the care and maintenance of Jean E. Albright. 27. Denied. It is specifically denied that the proper use: ofthe funds were the care of Jean E. Albright at the ManorCare facility. By way of further answer, any monies received by Deborah J. Johnson on behalf of Jean E. Albright were used for the care and maintenance of Jean E. Albright. 28. Denied. It is specifically denied that Deborah 1. Johnson knew that she obligated to pay any funds over to ManorCare for the costs of Jean E. Albright's care at the facility. By way of further answer, any monies received by Deborah 1. Johnson on behalf of Jean E. Albright were used for the care and maintenance of Jean E. Albright. 29. Denied. It is specifically denied that Deborah J. Johnson gave no consideration for the funds ofJean E. Albright received by Deborah J. Johnson. By way offurther answer, any monies received by Deborah J. Johnson on behalf of Jean E. Albright were used for the care and maintenance of Jean E. Albright. 30. Denied. It is specifically denied that demand has been made for Deborah J. Johnson to tender the funds of Jean E. Albright. It is further denied that Deborah J. Johnson has failed and refused to return said funds. By way of further answer, any monies received by Deborah J. Johnson on behalf of Jean E. Albright were used for the care and maintenance of Jean E. Albright. WHEREFORE, Defendant Deborah J. Johnson respectfully requests that this Honorable Court find in her favor and against Plaintiff. RUSSELL, KRAFFT & GRUBER, L.L.P. {~ ~ Gary G. Atty.ID .19351 Hempfield Center, Suite 300 930 Red Rose Court Lancaster, P A 17601 Telephone: (717) 293-9293 Facsimile: (717) 293-5130 VERIFICATION I, Deborah J. Johnson, verify that the averments or denials off acts contained in the foregoing Answer are true and correct to the best of my knowledge, infomlation, and belief. I understand that the statements herein are made subject to the penalties of 18 Pa.C.S. ~ 4904, relating to unsworn falsification to authorities. Dated: 12-~ 101 / / ." ~ l n'~' \'- \ \, )j I" (k..-J Ji, ~ ~ .d\r.'-. Deborah 1. Jo so IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC. Plaintiff Docket No. 2004-4776 v. DEBORAH J. JOHNSON a/k/a DEBRA J. JOHNSON Defendant CERTIFICATE OF SERVICE I hereby certify that on the date set forth below, I served upon the following person(s) and in the manner indicated below, a true and correct copy of Defendant's Answer to Plaintiffs Amended Complaint in the above captioned matter. Service via First Class Mail and addressed as follows: David A. Baric, Esquire O'BRIEN, BARIC & SCHERER 19 West South Street Carlisle, P A 18013 RUSSELL, KRAFFT & GRUBER, L.L.P. Dated: ''l;6tf 0 "'-) 0 c;-::) , < :J -n - --I C., :T: -11 r'-1 rll i'" ...-'J I :'fJ~5 -.J i~/) ! -T -ry " ) ~:5 -) c'n <:':? I C) J (...) ~< , GARY G. KRAFFT, ESQUIRE ATTORNEY LD. #19351 RUSSELL, KRAFFT & GRUBER, LLP 930 RED ROSE COURT, SUITE 300 LANCASTER, PA 17601 TELEPHONE (717) 293-9293 FACSIMILE (717) 293-5130 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTiON - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, a/k/a DEBRA J. JOHNSON, Defendant PETITION TO WITHDRAW AS LEGAL COUNSEL I. Petitioner is Gary G. Krafft, Esquire, and Russell, Krafft & Gruber, LLP, counsel for Defendant in the above-captioned action. 2. Respondent is Deborah J. Johnson, a/k/a Debra J. Johnson, Defendant in the above-captioned action. 3. Petitioner has represented Defendant in these proceedings since October 2004. 4. By letter dated January 31,2006, Petitioner requested Respondent to contact him for the purpose of scheduling depositions. 5. On March 6, 2006, Petitioner again wrote to Respondent, but Respondent has continued to ignore Petitioner's correspondence. 6. Due to Respondent's failure to communicate with Petitioner, it has become impossible for Petitioner to adequately represent Respondent. 7. In addition, Respondent currently owes Petitioner $2,862.1 0 and has failed to pay Petitioner on a regular basis for services rendered. 8. There are no pending hearings or conferences and, therefore, Respondent would not be prejudiced by the court granting Petitioner's request to withdraw. 9. This matter has not been assigned or ruled on by any prior Judge. WHEREFORE, your Petitioner respectfully requests that the Court enter an Order granting leave for counsel to withdraw his appearance on behalf of the Defendant, Deborah J. Johnson, alkla Debra J. Johnson. RUSSELL, KRAFFT & GRUBER, LLP ~ af Attorn I.D. # 19351 Hempfield Center, Suite 300 930 Red Rose Court Lancaster, PA 17601 Telephone: (717) 293-9293 Facsimile (717) 293-5130 - 2 - VERIFICATION I verify that the statements made in the foregoing Petition are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. S 4904 relating to unsworn falsification to authorities. Date: March ~, 2006 ~ b~~ ~. -F", Gary .' GARY G. KRAFFT, ESQUIRE ATTORNEY I.D. #19351 RUSSELL, KRAFFT & GRUBER, LLP 930 RED ROSE COURT, SUITE 300 LANCASTER, PA 17601 TELEPHONE (717) 293-9293 FACSIMILE (717) 293-5130 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, alk/a DEBRA J. JOHNSON, Defendant VERIFICATION OF SERVICE I verify that I served a true and correct copy of a Petition to Withdraw as Legal Counsel on the following persons and in the manner indicated below. Service bv First Class Mail Addressed as Follows: Ms. Deborah J. Johnson 25 Savo Avenue Lancaster, PA 17601 David A. Baric, Esquire O'Brien, Baric & Scherer 19 West South Street Carlisle, P A 17013 RUSSELL, KRAFFT & GRUBER, LLP -fer Gary G. Attorn I.D. #1935 Hempfield Center, Suite 300 930 Red Rose Court Lancaster, P A 17601 Telephone (717) 293-9293 Facsimile (7]7) 293-5130 Date: March~, 2006 121469.1 C) c~ ", C~:) ,'.-.:) ,.;:;;.... o -n --I :1: ,'" ril--4 ,-- -r-:f~l .-:) C) "".-~ {!'j T:::J~ : ,-? (~'5 ;~~~~ n1 ":"5 "< :?:': ).. ::0 N o -n (;? -.l .-f ..' RECEIVED MAR 2 2 2006 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, alk/a DEBRA J. JOHNSON, Defendant RULE ,- AND NOW this Z J. dayof 1'\-14,"4 ,2006, upon consideration of the Attached Petition To Withdraw as Legal Counsel, a Rule is hereby issued upon Defendant, to show cause, if any there be, why the relief requested therein should not be granted. Rule returnable in z 0 days. BY THE COURT: q~/I * / / / J. SD ~','<,F\8 .n -0 112 tlVtt! goaz ~o GARY G. KRAFFT, ESQUIRE ATTORNEY LD. #19351 ROXANNE C. GARNER, ESQUIRE ATTORNEY LD. # 87406 RUSSELL, KRAFFT & GRUBER, LLP HEMPFIELD CENTER 930 RED ROSE COURT, SUITE 300 LANCASTER, P A 17601 (717) 293-9293 FAX: (717) 293-5130 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, 1NC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH 1. JOHNSON, alkla DEBRA J. JOHNSON, Defendant MOTION TO MAKE RULE ABSOLUTE I. On March 22, 2006, Petitioner, Gary G. Krafft, Esquire, and Roxanne C. Garner, Esquire, of Russell, Krafft & Gruber, LLP, filed a Petition To Withdraw as Legal Counsel. 2. The Honorable Kevin A. Hess entered a Rule dated March 23, 2006, returnable in writing no later than April 11, 2006, to show cause why Petitioner should not be granted leave to withdraw his appearance, a true and correct copy of which Rule is attached hereto as Exhibit" A." 3. Attached hereto as Exhibit "B" is a Certificate of Service verifying Respondent, Deborah J. Johnson, alkla Debra J. Johnson, was served with a true and correct copy of the Court's Rule dated March 23,2006. 4. Said service via first class mail to Deborah J. Johnson was not returned and therefore, by rule of law, was presumed received by Defendant. No. 2004-04776 5. No response to the March 23, 2006 Rule and Petition to Withdraw as Legal Counsel has been filed by Respondent. 6. Respondent, Deborah J. Johnson, a/k/a Debra J. Johnson was notified that this Motion to Make Rule Absolute would be mailed to the Cumberland County Prothonotary on April 25, 2006 for filing with the Court, as set forth in the Certificate of Service attached hereto. RUSSELL, KRAFFT & GRUBER, LLP q,~ Roxanne C. Gamer Attorney J.D. # 87406 Hempfield Center, Suite 300 930 Red Rose Court Lancaster, PA 17601 (717) 293-9293 - 2 - RECEIVED MAR 2 2 2006 B Y IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, alkJa DEBRA J. JOHNSON, Defendant RULE AND NOW this m day of ff!.1H I' A ,2006, upon consideration of the Attached Petition To Withdraw as Legal Counsel, a Rule is hereby issued upon Defendant, to show cause, if any there be, why the relief requested therein should not be granted. Rule returnable in ~ days. BY THE COURT: J. . EXHIBIT "A" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, alkla DEBRA J. JOHNSON, Defendant CERTIFICATION OF SERVICE I hereby certify that on the 28th day of March, 2006, I caused service upon the person and in the manner indicated below, a Rule signed by the Honorable Kevin A. Hess on March 23, 2006, in the above-captioned action, which service satisfies the requirement ofPa.R.C.P. 440: Service bv First Class Mail and bv Certified Mail Addressed as Follows: Ms. Deborah 1. Johnson 25 Savo Avenue Lancaster, PA 17601 RUSSELL, KRAFFT & GRUBER, LLP ~~ ~::m . J.D. # 35~ Roxanne C. Garner Attorney J.D. # 87406 Hempfield Center, Suite 300 930 Red Rose Court Lancaster, P A 17601 (717) 293-9293 EXHIBIT "B" IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, a/k/a DEBRA J. JOHNSON, Defendant CERTIFICATION OF SERVICE I hereby certify that on this 25th day of April, 2006, I caused service upon the following person and in the manner indicated below, of a true and correct copy of the Motion to Make Rule Absolute. Service bv First Class Mail Addressed as Follows: Ms. Deborah J. Johnson 25 Savo Avenue Lancaster, PA 17601 RUSSELL, KRAFFT & GRUBER, LLP Gary G. raf Attorne I.D. #19 1 Roxanne C. Garner Attorney I.D. # 87406 Hempfield Center, Suite 300 930 Red Rose Court Lancaster, PA 17601 (717) 293-9293 123956.1 i , . ~ I<..E.C f-;: GARY G. KRAFFT, ESQUIRE ATTORNEY LD. # 19351 ROXANNE C. GARNER, ESQU1RE ATTORNEY LD. # 87406 RUSSELL, KRAFFT & GRUBER, LLP 930 RED ROSE COURT, SUITE 300 LANCASTER, PA 17601 (717) 293-9293 FAX (717) 293-5130 APR272006. \IW:~J?_1=c==1 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, a1k/a DEBRA J. JOHNSON, Defendant ORDER AND NOW, this za" day of 14j"" / , 2006, upon consideration of the attached Motion, no response having been made by Defendant, Deborah J. Johnson, alkJa Debra J. Johnson, this Court's March 23, 2006 Rule is made absolute, and Petitioners, Gary G. Krafft, Esquire, and Roxanne C. Garner, Esquire, of Russell, Krafft & Gruber, LLP, are granted leave to withdraw their appearance as counsel for Deborah 1. Johnson, a1k/a Debra J. Johnson. BY THE COURT: ./l~ J. '{ I\C), D lo O~"ty -, /, .- 'l GARY G. KRAFFT, ESQUIRE ATTORNEY I.D. #19351 ROXANNE C. GARNER, ESQUIRE ATTORNEY I.D. # 87406 RUSSELL, KRAFFT & GRUBER, LLP HEMPFIELD CENTER 930 RED ROSE COURT, SUITE 300 LANCASTER, PA 17601 (717) 293-9293 FAX: (717) 293-5130 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL V ANlA CIVIL ACTION - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, aIkIa DEBRA J. JOHNSON, Defendant PRAECIPE TO THE PROTHONOTARY: Please withdraw the appearance of Gary G. Krafft, Esquire, and Roxanne C. Gamer, Esquire, of Russell, Krafft & Gruber, LLP, on behalf of Deborah 1. Johnson, aIkIa Debra J. Johnson, in accordance with leave to withdraw their appearance granted by the Court by Order dated April 28, 2006, a copy of which is attached hereto. Dated: May 2, 2006 RUSSELL, KRAFFT & GRUBER, LLP ~ Gary . Atto y I.D. #19351 Roxanne C. Gamer Attorney I.D. # 87406 Hempfie1d Center, Suite 300 930 Red Rose Court Lancaster, P A 17601 (717) 293-9293 ./' 124349.1 ~ '. REeFJ .~ APR 2 7 Z006 GARY G. KRAFFT, ESQUIRE ATTORNEY !.D. # 19351 ROXANNE C. GARNER, ESQUIRE ATTORNEY 1.D. # 87406 RUSSELL, KRAFFT & GRUBER, LLP 930 RED ROSE COURT, SUITE 300 LANCASTER, PA 17601 (717) 293-9293 FAX (717) 293-5130 BY: IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION - LAW HCR MANORCARE, INC., Plaintiff vs. No. 2004-04776 Civil Term DEBORAH J. JOHNSON, a/k/a DEBRA J. JOHNSON, Defendant ORDER AND NOW, this x.~~y of , 2006, upon consideration of the attached Motion, no response having been made by Defendant, Deborah 1. Johnson, a/k/a Debra J. Johnson, this Court's March 23, 2006 Rule is made absolute, and Petitioners, Gary G. Krafft, Esquire, and Roxanne C. Gamer, Esquire, of Russell, Krafft & Gruber, LLP, are granted leave to withdraw their appearance as counsel for Deborah J. Johnson, a/k/a Debra J. Johnson. cc: Gary G. Krafft, Esquire Ms. Deborah 1. Johnson ~ , .,.'. ,.; mJ "1~ " -, -,-, -..'~ 5":-;'l: "'., ~J - f"-.J (~., C::) c;... C) " .--1 ::.1 nl" ,-- -'"') ~l; ! ~r~ ~ ..:-<.. -< '..J . il HCR MANORCARE, INC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004- 04776 CIVIL TERM DEBORAH J. JOHNSON, a/k/a DEBRA 1. JOHNSON, Defendant. CIVIL ACTION-LAW PRAECIPE TO DISCONTINUE TO THE PROTHONOTARY: Kindly mark the above-captioned action as having been settled and discontinued without prejudice. Respectfully submitted, DATE: AugustL,2006 lI::lJH David A. Baric, Esquire J.D. 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 II "- HCR MANORCARE, INC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA V. NO. 2004- 04776 CNIL TERM DEBORAH J. JOHNSON, a/k/a DEBRA J. JOHNSON, Defendant. CNIL ACTION-LAW CERTIFICATE OF SERVICE I hereby certify that on August --'-,2006, I, David A. Baric, Esquire of O'Brien, Baric & Scherer, did serve a copy ofthe Praecipe To Discontinue, by first class U.S. mail, postage prepaid, to the party listed below, as follows: Deborah J. Johnson 25 Savo Avenue Lancaster, Pennsylvania 17601 David A. Baric, Esquire .... c t"l' ::;:! I ::,~ 'C :, ~.: :... ' 1 . \ \-,;