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HomeMy WebLinkAbout12-1506 IN THE COURT OF COMMON PLEAS OF C ' n CUMBERLAND COUNTY PENNSYLVANIA _ CHURCH OF GOD HOME, INC., Plaintiff Docket No. - CIVIL ACTION - EQUITY RUTH AUBIN, individually and by and through her Agent, MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, Defendants. NOTICE TO DEFEND Pursuant to PA RCP No. 1018.1 YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after their complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the Church of God. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THEIR OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THEIR OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 S. Bedford Street 7 S d a Carlisle, PA 17013 Phone: (717) 249-3166 or (800) 990-9108 L S?11?? /z? ???/L S EN LA CORTE DE ALEGATOS COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, Docket No. V. CIVIL ACTION - EQUITY RUTH AUBIN, individually and by and through her Agent, MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, Defendants. AVISO PARA DEFENDER Conforme a PA RCP Num. 1018.1 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 Phone: (717) 249-3166 or (800) 990-9108 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, V. Docket No. RUTH AUB IN, individually and by and through her Agent, MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, CIVIL ACTION - EQUITY Defendants. COMPLAINT AND NOW, comes Church of God Home, Inc. ("Church of God"), by and through its attorneys, SCHUDER BOGAR, and files the within Complaint against Defendants Ruth Aubin ("Defendant Aubin") and Michael Bless ("Defendant Bless"), (collectively, "Defendants"), and in support thereof, provides as follows: 1. Church of God is a corporation created and existing under the laws of the Commonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 2. Defendant Aubin is an adult individual who currently resides at 4837 East Trindle Road, Mechanicsburg, Pennsylvania 17050. Defendant Aubin was a prior resident of Church of God's skilled nursing facility located at 801 North Hanover Street, Carlisle, Pennsylvania 17013 from March 14, 2011 to October 28, 2011. 3. Defendant Bless is an adult individual who currently resides at 22 Summit Place, Cedar Hill, Texas 75104. Defendant Bless is the son of and Agent for Defendant Aubin. See Power of Attorney attached hereto as Exhibit "A" and incorporated by reference. 4. On or about March 14, 2011, Defendant Aubin was admitted to Church of God's skilled nursing facility. 5. At the time of Defendant Aubin's admission to Church of God's skilled nursing facility, and at all times relevant hereto, Defendant Bless was operating as Defendant Aubin's Responsible Parry and Agent under a Power of Attorney. 6. On or about March 14, 2011, Church of God and Defendants entered into a written Nursing Care Admissions Contract ("Agreement"), pursuant to which Church of God agreed to provide Defendant Aubin with skilled nursing services in exchange for, inter alia, Defendants' promise to pay a specific monetary fee from Defendant Aubin's resources and promise to "complete the application and enrollment process for Medical Assistance benefits... in a timely manner." See Agreement pg. 9. A true and correct copy of the Agreement is attached hereto as Exhibit "B" and incorporated by reference. 7. The Agreement also assigned to Church of God Defendant Aubin's right to apply for and obtain Medical Assistance benefits ("Assignment") 8. Additionally, in furtherance of that Assignment, Defendants "irrevocably authorize[d] the Facility to make claims and to take such other actions as maybe necessary for the Facility's receipt" of those benefits in order to "satisfy charges under [the] Agreement." See Agreement pg. 51. 9. After Defendant Aubin was admitted to Church of God's skilled nursing facility, she allegedly became insolvent and her bills for skilled nursing care went unpaid. 2 10. As a result, an application for Medical Assistance benefits was filed on Defendant Aubin's behalf with the Cumberland County Assistance office ("CAO") on or about July 2011. 11. On November 29, 2011, the CAO issued a denial of Defendant Aubin's application for Medical Assistance benefits. See PA-162 attached hereto as Exhibit "C" and incorporated by reference. 12. Specifically, the CAO denied Defendant Aubin's application because Defendant Aubin was over the applicable Medicaid resource limit, and thus, was ineligible for assistance. See Exhibit "C." 13. After receiving the denial notice of benefits, Church of God appealed the decision on behalf of Defendant Aubin on December 19, 2011. This appeal was supplemented by Church of God's attorneys, SCHUTJER BOGAR, on December 22, 2011. 14. A hearing on this appeal has been scheduled for March 14, 2012. See Notice of Hearing attached hereto as Exhibit "D." 15. Defendants have been made aware of the necessity of spending down Defendant Aubin's excess resources in order to qualify her for Medical Assistance benefits, and Defendant Bless has repeatedly made assurances that the resources would be spent down and proof of same would be provided to Church of God. See February 24, 2012 correspondence attached hereto as Exhibit "E." 16. To date, however, Defendants have not provided said proof to either the CAO or Church of God. 17. Thus, although Church of God has preserved Defendant Aubin's right to pursue Medical Assistance benefits through the filing of a timely appeal, if Defendants continue to refuse to cooperate in the Medical Assistance eligibility determination process by failing to 3 appropriately spend down Defendant Aubin's countable resources on allowable medical expenses by the March 14. 2012 hearing date, the appeal will fail. Therefore, Church of God will be precluded from receiving the Medical Assistance benefits that have been contractually assigned to it for the skilled nursing services provided to Defendant Aubin from March 14, 2011 through October 28, 2011. 18. To date, an outstanding balance of Thirty Thousand, Three Hundred and 99/100 ($30,300.99) Dollars is owed to Church of God for the skilled nursing services it provided to Defendant Aubin under the Agreement See Invoice attached hereto as Exhibit "F" and incorporated by reference. COUNT I BREACH OF CONTRACT/SPECIFIC PERFORMANCE CHURCH OF GOD v. DEFENDANTS 19. The allegations contained in Paragraphs 1 through 18 are incorporated by reference as though restated in full. 20. Pursuant to the Agreement entered into with Church of God, Defendants agreed to cooperate fully with the Medical Assistance determination process and to pay Church of God from the resources and assets belonging to Defendant Aubin. 21. Church of God provided skilled nursing services to Defendant Aubin pursuant to the terms of the Agreement. 22. However, in breach of the Agreement, Defendants have not cooperated fully with Church of God to secure Medical Assistance payments for Defendant Aubin's care; in fact, Defendant Aubin was deemed ineligible for Medical Assistance benefits towards the cost of long term care precisely because Defendants refused to appropriately spend down Defendant Aubin's countable assets on allowable medical expenses so that she could qualify for Medical Assistance 4 benefits. 23. If Defendants fail to appropriately spend down Defendant Aubin's countable resources on allowable medical expenses by the March 14, 2012, hearing, the appeal will fail and Defendant Aubin will not be eligible for Medical Assistance benefits. 24. Therefore, if Defendants fail to appropriately spend down Defendant Aubin's countable resources on allowable medical expenses by the March 14, 2012 hearing, Church of God will remain unpaid for the skilled nursing services it provided to Defendant Aubin from March 14, 2011 through October 28, 2011. Therefore, Church of God is precluded from receiving the benefit Defendants assigned to it. 25. Upon information and belief, at all times material hereto, Defendant Aubin has been financially unable to fully compensate Church of God for the services that it has rendered to her in accordance with the terms and conditions of the Agreement. 26. Defendants' breach of the Agreement with Church of God has irreparably harmed and continues to cause Church of God irreparable harm. 27. Only a decree of specific performance will adequately protect the interests of Church of God and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Church of God respectfully requests that this Court enter an Order requiring the specific performance of Defendants' contractual obligations under the Agreement, specifically requiring Defendants immediate cooperation in the Medical Assistance benefits process, including, but not limited to: (1) immediately executing the Authorization Statement; (2) requiring that Defendants spend down any excess assets of Defendant Aubin in accordance with applicable Medical Assistance regulations and provide proof of same to Church of God by the 5 March 14, 2012 hearing; (3) ordering Defendants to timely and completely accommodate any other requests made by the CAO within five (5) days of written notice by Church of God; and (4) ordering Defendants to recover and return all resources belonging to Defendant Aubin which were transferred at less than fair market value or were not utilized solely for Defendant Aubin's best interests. Dated: Za (7; By: 6 Respectfully submitted, SCHUTJER BOGAR Kirk Soliohage, Esq. PA Attorney I.D. No. 77851 1426 N. 3rd Street, Suite 200 Harrisburg, PA 17102 Phone: (717) 909-8160 Fax: (717) 909-5925 Ivana Grujic, Esq. PA Attorney I.D. No. 311922 309 Fellowship Road, Suite 200 Mount Laurel, NJ 08054 Phone: (856) 533-2464 Fax: (856) 533-2461 Attorneys for Church of God VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C.S.A. § 4904, relating to unsworn falsification to authorities. Dated: i ) [dA c? Coy o'ZD/? ?71 Karen Stephenson, Rep sentative of Church of God Home, Inc. J2,tir 5? c EXHIBIT "A" (TO COMPLAINT) .j ADVANCE HEALTH CARE DECLARATION (LIVI:NG WILL) AND HEALTH CARE POWER OF ATTORNEY OF RUTH AUSIN t, RUTH AUBIN, of 130 Tower Circle, Carlisle, Cumberland County, Pennsylvania, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent or unable to express myself. This declaration reflects my commitment to refuse life-sustaining treatment if I have a terminal or end-stage medical condition or am in a state of permanent unconsciousness, including a persistent vegetative state or irreversible coma. If I am in such condition or state, 1 direct my attending physician(s) to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, and that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might result from the withholding or withdrawal of Iife-sustaining treatment, even if such measures may hasten the moment of my death. Furthermore, if i am ever in such condition or state, I leave the following directions SAIDIS, LA WER & NOW r 6 VM H?o SCM1 Car". PA concerning my medical treatment: I do I do not [ l (y) want cardiac resuscitation. ( ) GQ want mechanical respiration. [ ) P'?l want tube feeding or any other artificial or invasive form of nutrition. t I do I do not (} [ .:.j want hydration (water) as may be necessary for my comfort. [ } [mil want blood or blood products. [ I want any form of surgery or invasive diagnostic tests. [ } want kidney dialysis. [ } [? want antibiotics or medication other than pain-relieving medication. [ } want chemotherapy. I realize that if I do not specify my preference regarding any of the forms of treatment listed above, I may receive that form of treatment. I designate the following person as my health care agent to make medical treatment decisions for me if I should become incompetent or unable to express myself, whether or not 1 have a terminal or end-stage medical condition or am in a state of permanent unconsciousness. Name and address of health care agents: Name: David GJA*n Address: 4q4 3 1Toledo. l3 ??3r Home Phone: - 31V } and Name: Michael R. Bless Address: SAIDIS, & -ADNVER LAW S We" Rio Suer( C2111sle. PA Dallas and Commerce, Texas Home Phone: qty - ?.?o- S..s"? POA. s- as ? My health care agent or substitute agents appointed hereunder shall have those of the following powers marked "Yes," subject to my directions in this Combined Living Will and Health Care Power of Attorney: 2 Yes No (:, ( ) 1. To authorize my admission to, or discharge from, a medical, nursing, residential, or similar facility and to enter into agreements for my care. L ( 1 2. To access, and to authorize others to access, any and all medical information and records of mine and/or about me; as my Personal Representative under the Health Insurance Portability and Accountability Act of 1996 (HiPAA), to receive my protected health Information and to auftwvize the disclosure and use of my protected health information as provided in 45 CFR Part 164. X ( 1 3. To employ and discharge medical and related personnel. ( ( [ 1 4. To authorize medication, surgical procedures, and/or other medical care for curative purposes, for treatment of specific symptoms, and to relieve pain. If I am suffering under a terminal condition from which i cannot recover, in the opinion of my attending physician, i specifically recognize and accept that an authorized medication and procedure to relieve pain or a specific symptom may accelerate my death. [ 5. To complete insurance, admission, and other health-related forms, applications, certifications, and documentation. { ] 6. To grant releases to health care professionals or institutions. {"'r ( 1 7. To authorize the donation of my anatomical parts. SrAJDIS, LOWER & MHUMMUM 6 Wet High Street Carlisle, AA [ [ 1 8. Any power herein to authorize an action shall also be deemed to be a power to deny or withhold authorization of specific acts. 9. Subject- to any substitutes named herein, to appoint successor or substitute health care agents hereunder. I hereby approve, ratify, and confirm any action taken by my said health care agent and substitute agent(s) appointed hereunder, until this Declaration is duty revoked under my hand and seal. This Combined Living Will and Health Care Power of Attorney and grant 3 Of Powers thereunder to my health care agent and substitute agent(s) shall not be affected by my disability, incapacity, incompetency, or by uncertainty as to whether I am dead or alive. I have signed this Declaration on this 15' day of April, 200$, Declarant's signature: Ruth Aubin Declarant's address: 130 Tower Circle Carlisle, PA 17013 The Declarant knowingly and voluntarily signed this writing by signature or mark in our presence. Witness's signatu : F Witness's address: 26 West High Street Carlisle, PA 17013 Witness's signature: l; Witness's address: 26 A t High Street Carlisle, PA '17013 SAM ?ISIYVVER ,& LINOW V?= H*b sneer Car". PA 4 ? IAN. 13, 2011 11.12AM NO. 7636 P. 2/6 THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DE MATE (YOUR 'AGENT') BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE PCYWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY. YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INOWACITATED, LKM$ YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEMALF TERMINATES YOUR AGENTS AUTHORITY. YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURT CAN TAKE AWAY THE POWER OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S, CH.66. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DQ 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. MY ATTORNEYS, SAIDIS, FLOWER & LINDSAY, HAVE EXPLAINED THIS NOTICE AND THE POWER OF ATTORNEY TO ASE, I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND I UNDERSTAND THE CONTENTS OF THESE DOCUMENTS. Data Ruth Aulln, PrIndpsl MAR. 13, 2011 11:12AM .s a• e? NO. 1636 P. 3/6 1, Ruth Aubin of North Middleton Township, Cumberland County, Pennsylvania (`Prtndpai?, hereby appoint Midi R. Ries of 22 Summit Piece, Cedar HE, Tees (hereinafter referred to as 'my Agec?' 7 my Agent. My Agent shall have full power of substIhMon, far me and in my name, to transact alt buslhees and to manage ail my property and affairs as l might do If psreonatty pr+Gent. i. 8peWcadon of Powers In addMon to the above general powers, my Agent and my Successor Agent shelf have the following specific powers: (1) To mane limited 9ft of my property, In equal amounts to my issue, including my Agent (2) To create, a trtwt for my benefit. (3) To make additions to an e>deting trust for my bwW t. (4) To claim an elective share of the estate of my+deceased spouse. (5) To dledalm any Ir r*st In property. (6) To renounce f•+dudery posiftons. (7) To withdraw and receive the income or corpus of a trust (8) To authodge my admission to a medical, nursing, residesff or similar facility and to enter into agregmeft for my cane. (9) To authorize medical and surgical procedures. (10) To engage In real property tansecfions. (11) To engage In tangible personal property transaction. (12) To engage In stock, bond and other securities transactions. (13) To engage in banking and fined transactions. (14) To borrow money. 2 MA'R, 18. 2011 11:12AM (1b) To enter safe deposit boxes. (16) To engage in Insurance transactions. (17) To engage in retirement plan transactions. (18) To handle Interest in estates and trusts. (19) To pursue clew and litigation. (20) To receive government benefit. (21) To pursue tax mfrs. (22) To make an anatomical glft of all or part of my body. N0.7636 P. 4/6 if. IVA&Agmft For the purpa of this Pm+ver, a MW from a duly4lowsed Phyak&n dKVnV t#rst sW exami>ft an Agent named herein is merbily or phy?sloak th y, ate such that he or On wain be u%ft toad as my Agent, shall be conclusta proof of such Ages Incep r, Ill. Q le Pow a! v. This Is a durable poww of shomsy and It shall not be 830cled by my subsequent dheability or incap y AN acts done by my Agent pursuant to this pMW shall have the earro effect and shall Inure to my ttwX* sM bind me and my sucosors In irtt wed as if I were compethnt and not mod. N. I hereby ratify and confirm all that my Agent or my Successor Agents shay kwfijly do or cause to be done by virtue hereof. V. a Ina L„?t. This power of 90cmay shall be constructed by and Interpreted in accordance with the taws of the Commonwealth of Pwwmylwnla. IN WfTtdESS WHEREOF, t have hereunto set my hod and seal on this, the 2e day of May, 2010. WITNESS: Rata AA, Princes 3 VI AR.13. 20 11 11:13AM NO, 7636 P. 5/6 COMMONWEALTH OF PENNSYLVANIA ? . ss. COUNTY OF CUMBBRLAND ) On #ftl the 2EP daty of May, 20% bekre rne, a notary pttbR% the undermined oft or, persondy eppeamd Rai Ambin known to me Ear e- arlly pmvert) to be the peen 4=9 n Mr subscribed to the wftNn Power of ABomey, and ad=wlec cd that she exomted the am for the pure therein o mWmd. IN VIFITNESS VM F, I have hereunto set my Mm and officW seal. 4 mu. 1e,ZU11 11:13AM N4.7636 P. 6/6 ACKNC LEGMENT BY AGENT AND S CE OR AGENT 1, Michael R. Bless, have read the attdhed Power of Attorney and am the person kderrflIlsd as the Agent for the principal. I heroby acknowledge that in the absence of a spec o pmnrlWo to the omt#retry in the pawOr of attorney or in 20 Pa.C.$, when I acct as argent: I shall w erdss the powsm for ft bww2 of dae primal. I shall keep the assets of ft principal separate from my assets. I aW kegp a full and eccumto record of ail melons, reoulple and +disbureemw is on behi f of the principal. 5 EXHIBIT 44B51 (TO COMPLAINT) 42 CHURM OF GOD HOME "Committed to Caring" Nursing Care Admissions Contract Information Church of God Home, Inc. 801 N. Hanover Street • Carlisle, PA 17013 P: (717) 249-5322 - F: (717) 249-8622 Revised 01/2011 4m? CHURCH OF GOD HOME "Committed to Curing" Dear Friend: Admission into a health care facility is a teaming experience, both for the new resident and their family. We at the Church of God Home try to make the admission process as positive, pleasant and easy as possible. Because of the number of documents that must be explained and signed upon admission, many facilities look at this as being °overwhelming". However, both State and Federal regulations require such forms for permanent records. As we welcome the new resident, a hand is extended in friendship... an arm is offered for support... a cheerful pat of encouragement is given... these are a few of the special touches that the Church of God Home has been offering since its doors first opened in 1948. For more then sixty years a Christian spirit has been the guiding philosophy of our Home. That's the reason our care goes far beyond just meeting the physical needs of our residents. We believe in the dignity and sell-worth of each individual, and every aspect of our care reflects that belief. Our mission is to minister to the physical, spiritual, and emotional need of each resident in order to help him or her lead a more meaningful life. In sharing these values and standards of the Church of God Home, we hope that our experience will benefit others so that, together, we will continue to find better ways to serve the needs of elderly people in our society. Carson G. Ritchie, CPA, NHA President/CEO 2 Table of Contents 1. Welcome Letter ..........................................................................................................................2 2. Statement of Vision and Mission .......................................................................................... .......4 3. Ambulance ........................................................................................................................... .......4 4. Chart of Costs ...................................................................................................................... ... 5-7 5. Dietary Services .................................................................................................................. ... 7-8 6. DVD "A Time of Transition" .................................................................................................. .......8 7. Guest Room ........................................................................................................................ .......8 8. America's Best Medical ....................................................................................................... .......9 9. Medicaid (Medical Assistance) ............................................................................................. 9-10 10. Medicaid (Medical Assistance) Residents ................................................................................11 11. Medicaid (Medical Assistance) Residents Checklist ........................................................... 12-13 12. Medicare .... ......................................................................................................................... 14-15 13. Mobile X-Ray Imaging, Inc ........................................................................................................16 14. Psychiatrist ...............................................................................................................................16 15. Smoke Free Environment .........................................................................................................17 16. Specialized Services ............................................................................................................ .....17 17. Transportation .................................................................................................................... ......17 18. Understanding Restraint Use ....................................................................................................18 19. Advance Directive Policy .................................................................................................... ......19 20. Complaint Procedure .......................................................................................................... ......20 21. Delegation of Responsibility Form ...................................................................................... ......21 22. 'Legal Rights Compliance .................................................................................................... ......22 23. Non-Discrimination Statement ............................................................................................ ......23 24. Personal Cash Accounts / Depleted Funds ........................................................................ 24-25 25. Personal Laundry Service ................................................................................................... ......26 26. Pharmacy Services ............................................................................................................. 27-34 27. Podiatry Services ................................................................................................................ ......35 28. Privacy Act Statement - Healthcare Records ..................................................................... 36-37 29. Private Room Policy / Nursing ............................................................................................ ......38 30. Therapy .............................................................................................................................. ......39 31. Vaccinations ....................................................................................................................... 40-445 32. Valuables ............................................................................................................................ ......46 33. Admission and Care Agreement ......................................................................................... 47-55 a. Security Deposit ........................................................................................................... ......47 b. Late Charge ................................................................................................................. ......48 c. Readmission - Bed Hold Policy ................................................................................... ......49 34. Resident / Family Guide to Inquiries and Information ......................................................... 53-54 35. 'Welcome' (Telephone/Extension) .................................................................................... ......55 36. Checklist ............................................................................................................ .... ......56 3 STATEMENT OF VISION AND MISSION Vision To provide an aging services' continuum of care that reflects the perfect love of Christ, exceeding the expectations of those we serve. Mission Church of God Home, a Continuing Care Retirement Community, is a Christian Ministry committed to caring for the body, mind and spirit of older persons. Admissions Policy It is the policy of the Church of God Home, a unit of the Eastern Regional Conference of The Churches of God, to admit and treat all persons without regard to race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. Only those applicants whose medical nursing care, psychological and behavioral needs can be adequately met by the staff, will be admitted or kept in this facility. In addition, all residents must meet the financial criteria of private pay, Medicaid or SSI payer source. The Board of Trustees is committed to providing housing, services and needed responsible care for older persons with priority to those who are members of, or affiliated with, the Eastern Regional Conference of The Churches of God. The same requirements for admission are applied to all, and residents are assigned within the facility without regard to race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. There is no distinction in eligibility for, or in any manner of, providing any resident service that is provided by or through the facility. All areas of the healthcare center are available to all persons and visitors regardless of their race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. All persons applying for admission, or who are recommending individuals to the Church of God Home, are advised to do so without regard to the person's race, color, national origin, age, ancestry, sex, handicap, disability, or religious creed. Ambulance Ambulance enrollment is recommended but is not handled by the facility. If you desire enrollment, please contact them independently. 4 Chart of Costs Nursing Care Room Rates Faith Wing and Love Wing Semi-Private $249.00 per day-- Private $302.00 per day Personal Care Room Rates Effective January 1, 2011 Hope Wing and Peace Wing ;Semi-Private $111.00 per day (Rm401411) Private $119.00 per day (Rm301) $130.00 per day (Rm303-313) $139.00 per day (Rm400) Creekside Apartments Studio One Bedroom One Bedroom, Creek view One person $153.00 per day $173.00 per day $178.00 per day Two persons $257.00 per day $284.00 per day $331.00 per day Note: There will be a security deposit charged based on a 31-day month at the per diem rate for roomifevel of care. In the event of a Level of Care change to a higher level the residentlresponsible party will be billed the difference between the security deposits. There are no additional charges while receiving benefits under the Medicare program while in nursing care (except telephone, hair care, personal laundry, transportation, bed hold, bed reserve and name labels). Independent Living Rates LeTort Manor Apartments Apartment Monthly Maintenance Fee One Person Two Persons A $942 $1,264 B $868 $1,170 C $868 $1,170 D $853 $1,160 E $853 $1,160 Apartment Type 40% Refundable Rate Non-Refundable Apartment "A" $109,000 $83,000 Apartment "B" $96.100 $73,000 Apartment "C" $96,100 $73,000 Apartment "D" $81,000 $63,000 Apartment "E" $81,000 $63,000 Independent Livine Rates - Rental Rates LeTort Manor Apartments A artment Monthly Rental One Person Two Persons A $2,000 $2,315 3 $1,800 $2,095 C $1,800 $2,095 D $1,600 $1,895 E $1,600 $1,895 Note: LeTort Residents who choose the monthly rental option will be charged a security deposit based on one month rental fee. 5 Chart of Costs (continued) Independent Living Rates Creekside Apartments A. ap rtment Monthly Rental One person Two Persons Studio $1,318 $1,803 One Bedroom $1,667 $2,313 Note: There will be a Security Deposit charged for Creekside Independent Living Residents based on the monthly rate. Ancillary Services Bed Hold (during hospitalization or LOA) Per Diem rate Cable Television (Nursing and Personal Care) Cable Television (Independent Living) Cable Internet Cable Modem Clothing Name Labels Guest Room (maximum stay of 5 nights) Incontinence Supplies Liners Briefs / Pull-ups Miscellaneous supplies Keys Laundry Service (personal clothing) Medication Assistance Charge (Independent Living) Medications, Medical and adaptive equipment, Alarm pads, special requests, etc. Nutritional Supplies 6 3 I Oxygen Concentrator Usage Portable Oxygen Usage CPAP, and Supplies Photocopies (copies of records) Private Telephone Purchase Telephone Set Monthly Line Fee Included $22.001month $20.00/month $62.00 one time fee Cost 1 person - $28.00/night 2 persons - $33.00/night 25% above cost 25% above cost 25% above cost $5.00 $33.75/month $15.00/month At own expense unless covered by your insurance or covered by medical assistance benefits 25% above cost $3.00/day, unless covered under Medicare $12.00/cylinder, unless covered under Medicare Actual cost $1.28/pg(1-20) $0.95/pg(21-60) $0.32/pg(61+) At own expense $30.60/month Therapy (physical, occupational, speech) Actual cost unless covered under Medicare or co-payment by secondary insurance Transportation Services 0-10 Miles (round trip) .......................$22.00 11-50 Miles (round trip) .................. $44.00 51-76 Miles (round trip) .................. $75.00 Escorts ....................................... $10.00/hour Chart of Costs (continued) Hair Care Wash & Set $13.00 Men's Cut $11.50 Wash, Set, & Color Rinse $14.20 Men's Cut & Wash $20.00 Wash & Blow Dry $14.00 Men's Cut & Mustache Trim $13.00 Wash, Blow Dry, & Color Rinse $15.20 Mustache Trim $1.50 Wash & Cut $21.00 Women's Cut $12.50 Cut, Wash, & Set $25.50 Tint $30.00 Cut, Wash, Set, & Rinse $26.70 Tint & Cut $42.50 Cut, Wash, & Blow Dry $26.50 Permanents $54.05 Cut, Wash, Blow Dry, & Rinse $27.70 Permanents & Color Rinse $55.25 Wash, no blow dry $8.50 Permanents; in bed $60.00 Oil Treatment, Shampoo, & Set $24.50 Men / Women Wash; in bed $16.10 Color Rinse $1.20 Men / Women Cut & Wash; in bed $28.35 Frost 1 Hi-Light $48.00 Wash, Style, & Blow Dry; in bed $29.40 Frost / Hi-Light & Cut $60.50 Re-comb $8.45 Re-comb & Curling Iron $11.75 Dietary Services The Dietary Department offers three (3) well-balanced nutritious meals daily as well as an alternate menu for personal preference. A PM snack is available upon request at no extra charge. The department employs two Certified Dietary Managers and a Consultant Registered Dietician to provide special diets and dietary consults with residents and families. Our five-week menu cycle offers a variety of homemade items and incorporates fresh fruits and vegetables when in season. Menus are posted in several locations throughout the Home. Our large meal of the day is served mid-day and called Dinner. Our evening meal is called Supper. General Guest Meal Policy Limit four (4) guests per resident (as space permits) for all meals except holidays. Reservations must be made 48 hours in advance for general guest meals. If reservations are not made 48 hours in advance, an alternate guest meal may be served at the discretion of the Dietary Department. Holiday Guest Meal Policy On the holidays of Easter, Mother's Day, Thanksgiving, and Christmas there is a limit of two (2) guests per resident. Due to the volume of guests that may wish to dine on these holidays, the Church of God Home will accommodate the first twenty-five (25) guests to register. Since it is impossible to provide this notice to all family members, please share this information with your extended family. Thank you for your understanding and cooperation. Families are encouraged to participate in special meal events throughout the year, such as our Parents Day and Holiday Buffet. 7 Extra Dietary Services (Arrangements for these provisions should be made through your Social Worker.) *You will receive a separate bill from our Business Office for these services. SIZE CAKES: SERVES COST wfTAX 9" Round - 2 layers 16 $22.00 %. Sheet -10"x14" 16 $15.00 Sheet -12"x17" 30 $20.00 Full 60 $30.00 ICE CREAM. Hand dipped - dishes $1.00 Hand dipped - 3 al, container $17.50 Dixie Cups - (24) 4oz. containers Vanilla / Chocolate $10.00 GUEST MEALS: Breakfast $5.00 Dinner $7.65 Supper $6.30 Sunda. and Holiday $7.65 MISCELLANEOUS: Potatoes Chips - 3 lbs. $9.75 Pretzels - 3 lb. $7.55 Punch -1 al. $4.00 Lemonade -1 al. $4.00 Iced Tea -1 al. $4.00 Cookies -1 doz. An Kind $3.50 NOTE: All of the above items include paper-serving products and must be ordered 1 week in advance. Special Orders will be priced b Dietary Department DVD "A Time of Transition" I acknowledge that I have viewed the DVD entitled "A Time of Transition" and have been provided the opportunity to ask questions. I further acknowledge that Guide One Insurance, the Home's insurance company, recommends a viewing of this DVD. ials) Guest Room - There is a cost per night with a maximum stay of five nights. A second person in the room is an additional charge per night. No young children please. Your friend or relative will be billed for their stay. Reservation can be made through the Residential Housing Administrator (717) 249-5322 extension 3085. 8 L I AMERICA'S BEST MEDICAL 2100 Gettysburg Road - Camp Hill, PA 17011 Phone 1-800-383-5303, Fax 1-800-814-9405 America's Best Medical provides Church of God Home residents with 24-hour Oxygen Service and Respiratory Supplies. They are accredited by the Community Health Accreditation Program providing weekly service to re- stock oxygen supplies, change disposable medical respiratory goods, and label and date concentrator supplies for State compliancy. Their Mission is dedicated to improving our resident's functional abilities and overall quality of life while providing high-quality products and services that meet the highest safety standards and levels of clinical proficiency. Their commitment to service and excellence ensures the premium quality of care expected by our residents and our Home. America's Best Medical Equipment Company bills the Church of God Home directly for services and supplies. Church of God Home then bills the individual residents. For residents covered under Medicare "Part A" or Medicaid, oxygen is included in the daily rate. Services to Personal Care Residents will be billed by America's Best directly to Medicare "Part B.' MEDICAID (MEDICAL ASSISTANCE) Medicaid provides Medical Assistance to low-income persons aged 65 or over, blind, disabled, or members of families with dependent children. The Federal and State Governments jointly finance this program and it is administered by the state. Within broad general Federal Regulations, each state decides eligibility, types and range of services, payment level of services, and istrative and operating procedures. Medicaid's major distinction from Medicare i a form of finanaa e. Medicare is a type of healthcare insurance. When resident resources are ced to $15,000.00, th ility Business Office should be noted immediately, The following instructions will a 1. Resident/Responsible party will be responsible for a burial reserve set up at a bank or funeral home with amount equalizing enough for burial. The amount set aside should include amount of life insurance plus additional funds. A copy of that agreement should be submitted to the Business Office. 2. When all assets are reduced to $2,000.00, call the Business Office for appointment for guidance in the enrollment process. It is the legal responsibility of the POA/Representative Payee to complete the application and enrollment process for Medical Assistance benefits. Every effort will be made by our Business Office staff to assist you. A checklist (pg12-13) is being provided to you with guidelines that will help you get started. Please be aware however, that if the POA/Representative Payee does not follow through in a timely manner, that the Church of God Home, Inc. reserves the right to file the application on the resident's behalf. 3. The Centre County Office of Aging will do a level of care assessment of the resident, known as an "Options Assessment" and forward the results to the Pennsylvania Department of Public Welfare (DPW) for further follow-up by the Centre County Assistance Office. Should they assess for a different level of care other than nursing, and/or the resident does not qualify for Medicaid, the facility reserves the right to terminate the admission agreement and will work with resident/responsible party regarding available options. 9 4. To appeal a decision regarding a Medicaid Assessment, contact: The Pennsylvania Department of Public Welfare Huntingdon County Assistance Office (Cumberland County Long Term Care Unit) 7591 Lake Raystown Shopping Center Huntingdon, Pennsylvania 16652-0398 P: (814) 641-6447, 800-237-7674 Fax: (814) 643-5441 To appeal a decision regarding a level of care assessment, contact: The Cumberland County Office of Aging Long Term Care Program Human Service Building 1100 Claremont Road Carlisle, Pennsylvania 17013 (717) 240-6110 5. After preliminary papers are sent to the assistance office, the resident's security deposit will be applied to room and board and any balance due billed to the responsible party. 6. After being approved, Medicaid requires that the resident's monthly income be submitted to the facility each month. Of that amount, the resident will receive the approved $45.00 monthly allowance for his/her personal needs. The resident, responsible party or the facility may handle this personal money. 7. Allowable expense from resident monthly income is health insurance. After acceptance into the Medicaid program, billing for health insurance should be forwarded to the staff in our business office. The monthly expense for this insurance is deducted from the resident's monthly income and the balance is applied to the room and board. The state pays the facility a per diem (daily) rate times the number of days in the month that a resident, approved for Medicaid, occupies an accommodation. After residents responsibility is applied to this amount, the balance is billed to the Pennsylvania Department of Public Welfare (DPW) on a monthly basis. Bills for personal needs may be presented in the resident's name to the facility handling funds for reimbursement. Upon enrollment into the Medicaid program, the resident will no longer pay for routine hair care, incontinence supplies, non-emergent medical appointment transportation or personal laundry service. Medicaid will, however, pay for prescription drugs, doctor visits, dental services and eye examinations. 8. Upon transfer or discharge for hospitalization of a resident receiving medical assistance benefits, the facility will hold a bed. 10 42b? CHURCH OF GOD HOME "Committed to Coring" Medicaid (Medical Assistance) Residents 1. The Church of God Home, Inc. requires a copy of monthly / quarterly Medical Insurance premiums. As REQUIRE., y ylvania State Regulations. i 2. Medical Insurance Pre ms will be deducted from the Resident's monthly income and the balance of the income less a 5.00 alig ance will be applied to room and board. 3. Prescription drugs, p?ysic' n visits, dental services, and eye examinations are covered by Medicaid, but only with parti ' tists and ophthalmologists. Potential charges wiN be discussed with responsible party on an individual basis, when requesting non-participating providers. 4. Services furnished at no charge to the Resident are as follows: ¦ Normal Shampoo every two weeks ¦ One perm every three months • Transportation to and from medical appointments is provided (Distance to appointments will be discussed on an individual basis) • Non-emergent ambulance transportation • Personal Laundry • Incontinent Supplies • Bed hold in the event of hospitalization The following services will be charged: • Any hair care request beyond the above list of provided services • Transportation for a personal use • Telephone basic charges, and long distance charges 5. Bed hold days due to hospitalization will be fifteen (15) days per hospital stay. Bed hold days due to therapeutic leave will be thirty (30) days per calendar year. -3-1!q- r( (Date) (esiden esponsible Party) (Resident Name //, A f (Facility Represen Medicaid (Medical Assistance) Resident's Checklist HUNTINGDON COUNTY ASSISTANCE OFFICE (Cumberland County Long Term Care Unit) 7591 Lake Raystown Shopping Center Huntingdon, Pennsylvania 166524398 Telephone: 1800.237.7674 or (814) 641.6447 In order to determine eligibility for nursing home Medicaid enrollment, the Centre County Assistance Office will need the following items to accompany your application when submitted by our billing office. (Photocopies are acceptable) Please call if you have any questions or need help in obtaining the required information. - 1.Social Security Card(s) 2. Proof of Date of Birth 3. Health Insurance Cards A. Medicare (Red/White/Blue Card(s)) B. Capital Blue Cross / Highmark Blue Shield Card(s) C. Any other health insurance plan(s) - 4. Health Insurance Premiums, provide frequency and amount - 5. Long Term Care Policies, provide monies received and terms - 6. Power of Attorney or Guardianship papers 7.Read HIPPA disclosure and complete the HIPAA disclosure request PW1815 _ 8. Verification of ALL GROSS VA income needed. (If you are not receiving benefits, you will need to apply for potential benefits in order to be eligible for Medicaid.) 9. Verification of ALL GROSS income - provide current award letters, pensions, annuity income, and interest income 10. Provide current statements for ALL bank accounts, stocks, bonds, trusts, IRAs, Keoghts, and Annuities - must provide values of - 11. Personal Care Account (PCA) Balance 12. Verification of all resources sold, transferred, or given away during the past 5years (5 years for a Trust Fund) - provide disposition, amounts, and dates 13. Titles, vehicle registration, and insurance for all vehicles owned, including boats, motorcycles, and trailers 12 14. Current cash value of all life insurance policies. Verification should include company's name, policy number, type of policy, face amount of policy when purchased, ownership of policy, and statement on the current cash value from the insurance company. 15. Deed to burial plot(s) or statement from cemetery 16. Copy of Burial Trust / Reserve (including Statement of Irrevocability) 17. Deed to all property and its current market value - if transferred or sold within the last 5 years, provide a copy of the new deed and the settlement sheet for all sold property _ 18. Title to mobile home and its current market value - if transferred or sold within the last 5 years, provide a copy of the new deed and the settlement sheet for all sold property 19. Any unpaid medical bills you wish to see if Medical Assistance would cover 20. Rent / Mortgage payment proof 21. Utility Bills A. Electric B. Gas C. Oil D. Heat E. Telephone F. Water G. Sewer H. Trash 22. Income Tax Returns - for the past 5 years, provide all schedules and 1099 Forms 13 I MEDICARE The Church of God Home participates in the Medicare program administered pursuant to Title XVIII of the Federal Social Security Act. Medicare hospital insurance helps pay for inpatient care in a Medicare-participating skilled nursing facility following a three (3) night hospital stay and your condition requires daily skilled nursing or rehabilitation services which, as a practical matter, can only be provided in a skilled nursing facility. A skilled nursing facility is a specially qualified facility, which has the staff and equipment to provide skilled nursing care or rehabilitation services and other related health services. Hospital insurance helps pay for care in a skilled nursing facility if all of the following five conditions are met: 1. You have been in a hospital at least three nights in a row, before your transfer to a participating skilled nursing facility. 2. You are transferred to the skilled nursing facility because you require care for a condition, which was treated in the hospital. 3. You are admitted to the facility within a short time, generally within 30 days after you leave the hospital. 4. A doctor certifies that you need, and you receive, skilled rehabilitation services on a daily basis, and 5. The Medicare intermediary or the facility's Utilisation Review Committee does not disapprove your stay All conditions must be met. It is especially important to remember the requirement that you must need skilled nursing care or skilled rehabilitation services on a daily basis. Skilled nursing care means care that can only be performed by, or under the supervision of, licensed nursing personnel. Skilled rehabilitation services may include such services as physical, occupational, and speech therapies performed by, or under the supervision of, a professional therapist. The skilled nursing care and skilled rehabilitation services you receive must be based on a doctor's orders. Hospital insurance will not pay for your stay if you need skilled nursing or rehabilitation services only occasionally, such as once or twice a week, or if you do not need to be in a skilled nursing facility to get skilled services. When your stay in a skilled nursing facility is covered by Medicare, hospital insurance helps pay for up to 100 days each benefit period, but only if you need daily skilled nursing care or rehabilitation services for that long. 14 If you leave a skilled nursing facility and are readmitted within 30 days, you do not have to have a new 3- night stay in the hospital for your care to be covered. If you have some of your 100 days left and you need skilled nursing or rehabilitation services on a daily basis for further treatment of a condition treated during your previous stay in the facility, Medicare will help pay. In each benefit period, hospital insurance (Medicare Part A) pays for all covered services for the first 20 days you are in a skilled nursing facility. For the 21 st through the 100th day, as long as you continue to meet the criteria for daily Skilled Nursing Care or Rehabilitation Services, hospital insurance pays for all covered services except for $141.50 a day. You may be charged up to this amount by the skilled nursing facility or it may be picked up by your secondary co-insurance. Effective May 30, 2008: Medicare requires that each resident / responsible party indicate their choice with regard to a bed hold if any nursing resident is hospitalized. Major services covered when you are in a skilled nursing facility Medicare hospital insurance (Medicare Part A) pays for these services: • A semi-private room, 2 beds in a room • All your meals, including special diets • Regular nursing services • Rehabilitation services, such as physical, occupational, and speech therapy • Drugs furnished by the facility during your stay • Blood transfusions furnished to you during your stay • Medical supplies such as splints and casts • Use of appliances such as a wheelchair • Oxygen usage i Some services not covered when you are in a skilled nursing facility I Medicare hospital insurance (Medicare Part A) does not pay for these services: • Personal convenience items such as a telephone in your room • Private duty nurses • Any extra charges for a private room unless it is determined to be medically necessary Transportation • Name Labels • Hair Care • Personal laundry service NOTE: If you disagree with a decision on the amount Medicare will pay on a claim or whether Medicare covers services you receive, you always have the right to appeal the decision. Feel free to contact Medicare at 1-800-6334227. The Church of God Home reserves the right to withdraw from the Medicare program. 15 MOBILE X-RAY IMAGING, INC. Mobile X-Ray Imaging, Inc. (•MXI•) is the most advanced, most efficient, most complete and the only local mobile diagnostic X-Ray/Uitrasound/EKG service in Central Pennsylvania. Based in Harrisburg, MXI employs technologists in Carlisle as well as both the East and West Shore areas of Harrisburg, making it convenient for us to provide fast efficient service to our customers throughout the region. We provide a broad range of mobile diagnostic services to our nursing home customers at the nursing facility, offering the convenience and comfort of having diagnostic studies performed in the home without the expense and discomfort of ambulance transportation. The following diagnostic services are available on 24 hours per day, 365 days per year basis: Diagnostic X-Ray Studies Electrocardiogram Services Holter Monitor EKG Diagnostic Ultrasound Examinations Our X-Ray and Ultrasound exams are interpreted by Quantum Imaging and Therapeutic Associates (formerly known as A.Z. Ritzman Associates), one of the foremost radiology physician practices in Central Pennsylvania. All EKG and cardiology related exams are interpreted locally by Associated Cardiologists, P.C. MXI has introduced the following significant improvements to the mobile diagnostic testing industry in Central Pennsylvania: ¦ MXI was the first provider to utilize sophisticated "high frequency" portable X-Ray units, which produce superior images with less radiation exposure. • We were the first mobile service in Central Pennsylvania to provide 24 hours a day, 7 days a week X-Ray service with round the clock interpretations. • We are the only mobile service in Central Pennsylvania, which does our own ultrasound examinations, which gives us complete control over quality and service efficiency. • We are the only mobile service in Central Pennsylvania to provide ultrasound service on 24 hours per day, 7 days a week basis, including interpretations. Our services are covered by Medicare, Medicaid and most major insurances. Mobile X-Ray Imaging, Inc. - 5120 Lancaster Street - Harrisburg, PA 17111(717) 561-4940 Psychiatrist The Church of God Home, Inc. offers psychiatric services specializing in geriatric services. Philhaven Hospital has contracted with the Church of God Home to provide on-site services for our senior adults. Billing for this psychiatric service will be as follows: • If the resident is private pay, Philhaven Hospital will bill Medicare first, then your supplemental insurance. If there is still a balance, then the responsible party will be billed. • If the resident is on Medical Assistance, Philhaven Hospital will bill Medicare first, then your supplemental insurance, and Medical Assistance third. There will be no bill to responsible parties. Feel free to contact Philhaven Hospital at (717) 270-2413 or 1-888-740-8211 if you need further clarification. We at the Church of God Home welcome this new dimension of expertise to our highly qualified staff. 16 Smoking Policy The Church of God Home does not permit smoking in any of our levels of care. Residents and visitors who smoke are asked to utilize the area provided outside the main entrance for this purpose. Employees and volunteers are not permitted to assist residents in meeting their smoking needs. It will be necessary for residents to get assistance from their family member and friends. All prospective residents will be informed of our Facility's smoking policy. Specialized Services If you have mental retardation, a physical disability, or other disability which occurred before the age of twenty-two (22), you may be eligible to receive support services that would help you to live with your family, in your own apartment, or in another community setting. You may also be eligible for specialized services. For more information, if you have mental retardation call Central Regional Office of Developmental Programs at (717) 772-6507. If you have another disability (other than mental retardation or mental illness) call United Disabilities Service at (717) 397-1841. If you have mental illness (other than dementia) and you do NOT need nursing facility services, you may be eligible to receive support services that would help you live in your own apartment, in a group home, or another community setting. For more information, call (717) 772-7490. If you are not satisfied with the response you receive, call the Disabilities Rights Network of PA at (215) 238-8070. Transportation Enrollment with the local ambulance service is not required, but is recommended. Not all medical appointments require ambulance stretcher transport and are often handled by our wheelchair lift van. Physician ordered medical appointments are to be scheduled through our nursing department with local physicians, as the Church of God Home does not normally transport to out-of-town medical appointments. Family members will be contacted to determine their availability to provide transportation, or to serve as a companion to accompany residents during transport, throughout the appointment, and on the return trip. Medical consult sheets accompany residents to their appointments and often there is a need to adjust for a meal or medication routine. Families providing transport are requested to follow the sign out procedures and are asked not to schedule follow-up appointments unless they are intending to provide the transportation. In either event, please be sure to inform the nursing department of the scheduled follow-up appointment. NOTE: Transportation provided by the facility will be at an extra charge. Please see "Chart of Cost" for fee schedule. 17 UNDERSTANDING RESTRAINT USE In order to protect our residents from harm or to promote them to a higher level of independence, it is sometimes necessary for us to use a physical restraint. Physical restraints are any manual method, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement or normal access to the resident's body. Examples include: bedside rails, leg restraints, arm restraints, hand mitts, soft ties, wheelchair safety bars and ged chairs. These devices are NEVER used as a disciplinary action or for the convenience of the facility to control behavior. Restraints are initiated only after less restrictive measures, such as positioning pillow, pads, wedges, removable lap trays couples with appropriate exercises, or other "enabling" equipment, have been demonstrated to be insufficient. The least restrictive device would be then implemented following a specific doctor's order and/or a phone call to P.O.A. / next of kin. The resident will then be reviewed in the next Restraint Reduction meeting. The following is a comparison of potential BENEFITS and RISKS of restraint use: Potential Benefits Prevention of falls which might result in injury • Protection from other accidents or injuries • Medical treatment allowed to proceed without resident interference • Protection of other residents/staff from physical harm Increased feeling of safety and security Potential Risks i • Accidental injury from the restraint Chronic constipation • Incontinence E Pressure sores j - Loss of muscle tone Loss of balance Reduced appetite, dehydration • Loss of independent mobility • Increased agitation ¦ Symptoms of depression, withdrawal • Contractures • Reduced social contact 18 CMRCH OF GOD HOME " Commitud to Caring" Advance Directive Policy It is God alone who opens the door to earthly life. It is God alone who has the right to close it. All experiences of life provide opportunities for evangelism, ministry, reconciliation and re-assessment of priorities. The Church of God Home recognizes the right of an individual to make and change decisions concerning their medical care in consultation with their physician. This includes the right to accept or refuse artificial means of sustaining life when these decisions are set forth in properly executed Advance Directives/Healthcare Guidelines. In no instance will the Church of God Home condone homicide, euthanasia, suicide or aided suicide. In the absence of advance directive, the care of the resident will be in accordance with currently accepted medical standards. Regardless of the resident's decision about life sustaining treatment, supportive and compassionate care for maximum comfort will be provided. These measures include, but are not limited to, oxygen, medication to relieve pain, food and fluids as tolerated, along with emotional and spiritual support. Should the occasion arise when a resident would refuse nutrition or medical supportive services with the intention of prematurely bring their life to an end, the Home would encourage and recommend counseling and evaluation. The family would be informed and, if a satisfactory resolution cannot be achieved as to the care of the resident, the Home would assist the family in the attempt to relocate the resident to another facility as soon as possible. I acknowledge that I have received a duplicate copy of the above Advance Directive Policy and have had provided the opportunity to ask questions relating to the same. I have also been offered the opportunity to complete an Advance Directive. -3- (Date) i (Resident/Responsible Party) (Resident Name) /I - - 'A (Facility Representativ 19 42b? CHURCH OF GOD HOME "Committed to Caring" Complaint Procedure Policy: It is the policy of the Church of God Home to have a complaint procedure in place to identify and address concerns. Purpose: To assure the Home's Mission Statement is being upheld to its highest integrity. Procedure: 1. Any written or oral complaints presented by or on behalf of a Resident to the Church of God Home regarding cane, operations, or management of the Home shall be directed to the Administrator of the facility. 2. If a resident wishes to make a written complaint but needs assistance, the Social Worker shall assist the resident in writing the complaint. 3. Within two (2) business days after notification of a written complaint, a status report will be provided to the complainant and/or designated person, explaining the steps that the Home is taking to investigate and address the complaint. 4. The Church of God Home shall ensure the Resident's safety if complaint identifies harm or potential harm. 5. Within seven (7) days after the notification of a written complaint, a copy of the written decision explaining the investigation findings and plans of action will be given to the complainant and/or designated person. 6. All complaints will be placed in a binder with the findings and plan of correction. The PCU Administrator will maintain the binder. I (Date) (Resid VResponsible Party) F (Resident Name) A C/114 (Facility Representative) 20 420b-z CHURCH OF GOD HOME "Committed to Caring" DELEGATION OF RESPONSIBILITY FORM As a result of medical and/or physical condition or personal choice, residents find it difficult to understand and/or sign for their Resident's Rights and/or their Admission contract. Some residents, although not legally judged incompetent, may be found by a physician to be incapable of understanding these rights and contract information. Therefore, a resident may choose to designate an individual to act of their behalf by permitting them to sign the necessary forms indicating receipt of this information. r is medically/physically capable of (Name of resident) understanding Resident's Rights but designates this to: _3I1/-It (Date) (ResidentlResponsible Party) (Resident Name) f (Facility Representativ 21 42b? CHURCH OF GOD HOME "Committed to Caring" LEGAL RIGHTS COMPLIANCE RESIDENTS AWARENESS COMMONWEALTH INFORMATION CENTER 402A Finance Building Harrisburg, PA 17120 Telephone: 1-800-932-0784 PENNSYLVANIA DEPARTMENT OF HEALTH DIVISION OF NURSING CARE FACILITIES HARRISBURG FIELD OFFICE 132 Kline Plaza, Suite B Harrisburg, PA 17104 Telephone: 717-783-3790 1 CUMBERLAND COUNTY AGING & COMMUNITY SERVICES OMBUDSMAN PROGRAM HUMAN SERVICES BUILDING 1100 Claremont Road Carlisle, PA 17013 Telephone: 717-240-6110 (Date) PENNSYLVANIA DEPARTMENT OF AGING 555 Walnut Street Harrisburg, PA 17101 Telephone: 717-783-7247 PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE HUNTINGDON COUNTY ASSISTANCE OFFICE (Cumberland County Long Term Care Unit) 7591 Lake Raystown Shopping Center Huntingdon, PA 16652-0398 Telephone: 814-641-6447 1-800-237-7674 MID PENN LEGAL SERVICES 401 East Louther Street Carlisle, PA 17013 Telephone: 717-243-9400 (ResidentlResponsible Patty) - if ` (? - A (Resident Name) (Facility Representaf 1'. 22 1 i 42 CMRCH Of GOD HOME "Committed to Caring" NON-DISCRIMINATION STATEMENT In accordance with applicable Federal and State civil right laws and regulatory requirements, you, as a resident of this facility, have the right upon admission: To be provided services at this facility and to be referred for services at other facilities without regard to your race, color, religion creed, handicap, ancestry, national origin, age or sex. ¦ To file a complaint of discrimination if you feel you have been discriminated against on the basis of your race, color, religious creed, handicap, ancestry, national origin, age, or sex. Complaints of discrimination may be filed with any of the following: PresidentlCEO Department of Health and Human Services Church of God Home, Inc. Office for Civil Rights 801 N. Hanover Street 150 S. Independence Mall West Carlisle, PA 17013 Suite 372 Phone: (717) 249-5322 Philadelphia, PA 19106-3499 Phone: (215) 861-4441 Pennsylvania Human Relations Commission Department of Public Welfare Harrisburg Region Office Bureau of Equal Opportunity Riverfront Office Center Central Regional Office 1101-1125 South Front Street, 5h Floor Rm # 223, Health & Welfare Bldg. Harrisburg, PA 171042515 P.O. Box 2675 Phone: (717) 787-9784 Harrisburg, PA 17120-2675 Phone: (717) 783-3063 ,3:j ?1- /1 (Date) (Resident/Responsible Party) (Resident Name) ,/, k7l, 'd (Facility Representative) 23 Personal Cash Accounts (PCA) To establish personal cash account (PCA) at the Church of God Home, Inc., contact our Business Office (Henderson House). The following procedure shall be followed: 1. Sign the following authorization form to open an account 2. Deposit money by checks or cash - A receipt will be issued for cash deposits. 3. Daily withdraw maximum of $30.00 Note: Regular business hours are 9:00 a.m. to 3:45 p.m., Monday through Friday, except holidays. Deposits i The resident or family member / responsible party may deposit cash or checks either at our Business Office (Henderson House) or in our Lobby Front Office during regular business hours and of course, by mail. Personal cash accounts are only meant to provide casual spending money for residents. Disbursements The resident may come to our Lobby Front Office during business hours to request money. A resident charge slip is completed and the resident or family member / responsible party sign the disbursement slip. Purchases for a resident may be made by family or designated person and a receipt should be submitted to our Business Office for each reimbursement from the resident's account, i.e. TV's, shoes, clothing, etc. PCA's are reconciled monthly to the bank statement. Interest paid by the bank is pro-rated to each account and deposited into each account accordingly. Quarterly statements are issued, along with a cover letter to be signed by the resident and returned to our Business Office. Each resident of the facility has the right to open a personal cash account (PCA). All accounts, regardless of the resident's status, are handled in the same manner. t Upon the death/discharge of a resident, the account balance shall be returned to the executor of their Will or authorized representative of their Estate within thirty (30) days. 51 24 Personal Cash Accounts (cont.) 4a cHtAtCN OF GOD HOME "Committed to Caring" Authorization to Handle Personal Funds ,3-1q It (Date) Depleted Funds 4A (ResidentlResponsible Party) c R (Resident Name) Y• (Facility Representa' When resident's assets reach $15,000.00, family/responsible party should contact our Business Office immediately. Family member / res arty will have to apply for Medical Assistance. Residents with no family member / responsible Tarty, ou, usiness Office will apply for Medical Assistance. Residents will receive 5.00 j onthly from their income for personal needs. Other monies may be deposited into each PCA, as the resident or family member / responsible party desires. 3_ty??t V?OA (Date) (R si esponsible Party) /P - -",,Y? (Resident Name) s V A(-I;ii (Facility Representativ } 25 CHURCH Of GOD HOME "Committed try Caring" Personal Laundry Service This is to advise that the personal laundry will be outside (circle one) the facility. NOTE: • These arrangements can be changed with notification to Social Services or Charge Nurse. • Residents / Responsible Parties providing laundry services need to provide a container with a lid and box of plastic bag liners for the purpose of storing laundry. • Volunteers are available to assist with labeling clothing I personal items. Please contact Social Services or Charge Nurse. • Dry cleaning and Alteration Services are not provided. • No wool items am accepted. (Date) (ResidentlResponsible Party) (Rest ent Name) V, A(", (Facility Representati 26 Pharmacy Services Specialist in 28 South 2" Street Newport, PA 17074 Continuing Care Rx is proud to announce that we have been chosen to be the provider of choice for the pharmacy services at Church of God Home. The mission of Continuing Care Rx is to provide pharmacy services and programs that meet the ever-changing needs of our facilities and the residents they serve, ensuring continued quality care and positive outcomes in the most cost-efficient manner possible. Pharmacy services for Long-Term Care or Personal Care Residences are mandated by government agencies to offer additional services, which you may not have been accustomed to in a normal retail pharmacy. These additional services are designed to aid in your progress (or that of your loved one). We would like to highlight some of the services we provide to give you a better understanding of the many unique benefits we have to offer the residents we serve: ? Controlled Packaging System - Routine tableticapsule medications are packaged in a 30-day sealed blister card enabling nursing staff to administer medications in a controlled environment with extreme accuracy and safety. ? Medical Records - A medical records staff member maintains and prints monthly charts that are utilized by the caregivers, nursing staff and physicians. ? 24-Hour Emergency Service - If a situation occurs that requires the delivery of medications in an emergency; Continuing Care Rx has a pharmacist and driver on call 24 hours a day, 7 days a week to meet these emergency needs. ? Consultant Pharmacist - A Consultant Pharmacist is assigned to our facilities to review residents' charts on a monthly basis and to interact with the nurses and physicians to monitor the residents' condition. In addition, they will make recommendations to the physicians when a better and more cost- effective therapy for the existing condition becomes available. ? Delivery Service - Medications will be delivered to the facility at predetermined times on a daily basis, ensuring timely delivery of all medications ordered. I ? Billing - The staff at Continuing Care Rx will handle the billing process for all types of reimbursement. Continuing Care Rx is a member of most insurance groups and we bill directly to these insurance groups. Should you belong to an insurance group with which we are not currently affiliated, we will immediately pursue enrollment in that program in an effort to meet your needs and ease your financial responsibility. We would like to point out that all of the above services are provided at no additional cost, thus ensuring a much more cost-effective and beneficial way of dispensing and monitoring our residents' medications. We, at Continuing Care Rx, are focused on providing the highest quality of pharmacy services to all of the residents we serve. We look forward to working closely with you (or your loved one) by providing the best service available in the long-term care industry. Note: Please contact Continuing Care RX with any questions or billing concerns at 1-800-675-2279. 27 i I Privacy Motet CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. I Lour Duty to Safeguard Your Protected Health Information We are committed to preserving the privacy and confidentiality of your health information. We are required by certain state and federal regulations to implement policies and procedures to safeguard your health information. Copies of our privacy policies and procedures are maintained in our business office. We are required by state and federal regulations to abide by the privacy practices described in this notice, including any future revisions that we may make to the notice as may become necessary or as authorized by law. Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care treatment or services you receive is considered protected health ie ormation (PHI). Accordingly, we are required to provide you with this Privacy Notice that contains information regarding our privacy practices to explain how, when and why we may use or disclose your PHI and your rights and our obligations regarding any such uses or disclosures. Except in specified circumstances, we must use or disclose only the minimum amount of PHI necessary to accomplish the intended purpose of the use or disclosure of such information. I We reserve the right to change this notice at any time and to make the revised or changed notice effective for PHI that we already have about you as well as any information we receive in the future about you. Should we revise(change this Privacy Notice, we will promptly post the revision [insert location, such as on a websitel. You also may request and obtain a copy of any newirevised Privacy Notice from the contact person identified on the last page of this mice. Should you have questions concerning our Privacy Notice, our contact information is listed on the last page of this document. i 11. How We May Use and Disclose Your Protected Health Information I We use and disclose protected health information for a variety of reasons. We have a limited right to use and/or disclose your protected health information for purposes of treatment, payment, or for health care operations. For other uses and disclosures, you must give us your written authorization to release your protected health information unless the law permits or requires us to make the use or disclosure without your authorization- Should it become necessary to release or give access to your protected health information to an outside party performing services on our behalf (e.g, maintaining our computers), we will require the party to have a signed agreement with us that the i party will extend the same degree of privacy protection to your information as we do. The privacy law permits us to make some uses or disclosures of your protected health information without your consent or authorization. The following describes each of the different ways that we may use or disclose your protected health information. Where appropriate, we have included examples of the different types of uses or disclosures. These include: 1. Use and Disclosures Related to Treatment We may disclose your protected health information to those who are involved in providing medical and nursing care services and treatments to you. For example we may release protected health information about you to nurses, nursing assistants, medication aides/technicians, medical and nursing students, therapists, other pharmacists, medical records personnel, other consultants, physicians, etc. We may also disclose your protected health information to outside entities performing other services relating to your treatment; such as long term care facilities, hospitals, diagnostic laboratories, home health/hospice agencies, family members. etc. 2. Use and Disclosures Related to Payment We may use or disclose your protected health information to bill and collect payment for items or services we provided j to you. For example, we may contact your insurance company, health plan, or another third party to obtain payment for services we provided to you. i Prvowy Novice 28 ¦ Pricacr .Notice 3. Use and Disclosures Related to Health Care Operations We may use or disclose your protected health information for the performance of certain fimcdons in monitoring and improving the quality of care and services that you and others receive. For example, we may use your protected health information to evaluate the effectiveness of the care and services you are receiving. We may also disclose your protected ing purposes. health information for auditing, care planning quality improvement, and learn 4. Use and Disclosures Related to Treatment Alternatives, Healtti-Related Benefits and Services We may use or disclose your protected health information for purposes of contacting you to inform you of treatment alternatives or health-related benefits and services that may be of interest to you, such as a newly released medication or treatment that has a direct relationship to a treatment or medical condition. 111. Uses and Disclosures Requiring Your Written Authorizatlim For uses and disclosures of your protected health information beyond the above excepted purposes, we are required to have your written authorization, except as otherwise required or permitted by law. You have the right to revoke an authorization at. any time to stop future uses or disclosures of your information except to the extent that we have already undertaker an action in reliance upon your authorization. Your revocation request must be provided to us in writing. Our contact information for purposes of revoking your authorization is listed on the last page of this document. You may use our Authorization for U3T or Disclosure of Protected Health Information form and/or our Revocation of an Authorization form to submit your request to us. Copies of these fiorms are available upon request. Examples of uses or disclosures that would require your written authorization include, but are not limited to, the following: I . A request to provide your protected health information to an attorney for use in a civil litigation claim. 2. A request to provide certain information to an insurance or pharmaceutical company for the purposes of providing you with information relative to insurance benefits or new medications that may be of interest to you. 3. A request to provide PHI to another individual or facility, where no exception from the written authorization requirement applies. IV. uses or Dfadosurse of Information Based Upon Your Verbal Agreernent in the following situations, we may disclose a limited amount of your protected health information if we provide you with an advance oral or written notice and you do not object to such release or such release is not otherwise prohibited by law. However, if there is an emergency situation and you are unable to object (e.g., because you were not present or you were incapacitated), disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interest. When a disclosure is made based on these or emergency situations, we will only disclose protected health information relevant to the person's involvement in your care. For example, if you are having an adverse reaction to a medication, and are not able to communicate with us effectively, we may inform a family member involved in your care of your drug regimen and possible side effects. You will be informed and given an opportunity to object to further disclosures of such information as soon as you are able to do so. We may disclose your protected health information to your family members and friends who are involved in your care or who help pay for your care. We may also disclose your protected health information to a disaster relief organization for the purposes of notifying your family and/or friends about your general condition, location, and/or status (i.e., whether you are alive or dead). You may object to the release of this information. You may use our Request to Restrict the Use or Disclosure of Protected Health Information form to notify us of your objection or your objection may be made orally. Our contact information is listed on the last page of this document. (See also Section V1, paragraph 1.) V. Uses and Disclosures of Information That Do Not Require Your Consent or Authorimtlon State and federal laws and regulations in some instances either require or permit us to use or disclose your protected health information without your consent or authorization. The uses or disclosures that we may make without your consent or authorization include the following: 1. When Required by Law: We may disclose your protected health information when required by federal, state or local law. Privacy Notice 29 Prnwy 1Vorice 2. Abuse, Neglect, or Domestic Violence: As required or permitted by law, we may disclose protected health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence. If such a report is optional, we will use our professional judgment in deciding whether or not to make such a report. If feasible, we will inform you promptly that we have made such a disclosure. 3. Communicable Diseases: i o the extent authorized by law, we may disclose information to a person who may have been exposed to a communicable disease or who is otherwise at risk of spreading a disease or condition. 4. Disaster Relief: We may disclose protected health information about you to government entities or private organizations (such as the Red Cross) to assist in disaster relief efforts. S. Food and Drug Administration (FDA): We may disclose protected health information about you to the FDA, or to an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to it drug or medical device. 6. For Public Health Activities: As required or permitted by law, we may disclose protected health information about you to a public health authority, for example, to report disease, injury, or vital events such as death. 7. For Health Oversight Activities: We may disclose your protected health information to a health oversight agency such as a protection and advocacy agency, or to other agencies responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents or to ensure that we are in compliance with applicable state and federal laws and regulations, including civil rights laws. S. To Coroners, Medical EsamineM Funeral Direetors, Organ Procurement Organizations or Tissue Banks: We may disclose your protected health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We may also disclose your protected health information to a funeral director for the purposes of carrying out your wishes and/or for the funeral director to perform his/her necessary duties. If you are an organ donor, we may disclose your protected health information to the organization that will handle your organ, eye or tissue donation for the purposes of facilitating your organ or tissue donation or transplantation. 4. For Research Purposes: We may disclose your protected health information for research purposes without your authorization only when a privacy board has approved the research project. We may use or disclose your protected health information to individuals preparing to conduct an approved research project in order to assist such individuals in identifying persons to be included in the research project. Researchers identifying persons to be included in the research project will not be permitted to remove protected health information from our control. If it becomes necessary to use or disclose information about you that could be used to identify you by name, we will obtain your written authorization before permitting the researcher to use your information. Researchers will be required to sign a Confidentiality and Non-Disclosure Agreement form before being permitted access to protected health information for research purposes. A sample copy ofthis agreement may be obtained from our business office. IQ. To Avert a Serious Threat to Health or Safety: We may disclose your protected health information to avoid a serious threat to your health or safety or to the beam or safety of others. When such disclosure is necessary, information will only be released to those law enforcement agencies or individuals who have the ability or authority to prevent or lessen the threat of harm. 11. For Judicial or Administrative Proceedings: We may disclose protected health information about you in the course of a judicial or administrative proceeding, in accordance with our legal obligations. Privacy Nrrtice 3 30 Privacr Nbrice 12. To Law Enforcement: We may disclose protected health information about you to a law enforcement official for certain law enforcement purposes. For example, vie may report certain types of injuries as required bylaw, assist law enforcement to locate someone such as a fugitive or material witness, or make a report concerning a crime or suspected criminal conduct. 13. Minors: If you are an unemancipated minor as defined under state law, there may be circumstances in which we disclose protected health information about you to a parent. guardian, or other person acting in loco parentis, in accordance with our legal and ethical responsibilities. 14. Parents: if you are a parent of an unemancipated minor, and are acting as the tninor's personal representative, we may disclose protected health information about your child to you under certain circumstances. For example. if we are legally required to obtain your consent as your child's personal representative in order for your child to receive care or services from us, we may disclose protected health information about your child to you. In some circumstances. we may not disclose protected health information about an unemancipated mina to you. For example, if your child is legally authorized to obtain services (without separate consent from you), and does not request that you be treated as his or her personal representative, we may not be required to disclose protected health information about your child to you without your child's written authorization. 15. To Personal Representatives: if you are an adult or emancipated minor, we may disclose protected health information about you to a personal representative authorized to act on your behalf in making decisions about your health care. 16. For Specific Government functions; We may disclose protected health information about you for certain specialized government functions. as authorized by law. Among these functions are the following: military command; determination of veterans benefits; national security and intelligence activities; protection of the President and other officials; and the health, safety, and security of correctional institutions.. 17. For Workers' Compensation: We may disclose protected health information about you for purposes related to workers' compensation, as required and authorized by law. VI. Your Rights Regarding Your Protected Health htfotmation Y..)u have the following rights concerning the use or disclosure of your protected health information that we create or that we may maintain about you: 1. To Request Restrictions on Uses and Disclosures of Your Protected Health information: You have the right to request that we limit how we use or disclose your protected health information for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care or services. For example. you could request that we not disclose to family members or friends information about a medical treatment you received. Should you wish a restriction placed on the use and disclosure of your protected health information, you must submit such request in writing. Such request should be submitted using our Request to Restrict the Use and Disclosure of Protected Health Information form. Our contact information for purposes of making such a request is listed on the last page of this document. We are not required to agree to your restriction request. You will be informed if we decline your request. If we accept your request, we will comply with your request not to release such information unless the information is needed to provide emergency care or treatment to you. .fivacy Notice 31 Privacy Noo" 1. The Right to Inspect and Copy Your Health and Billing Records: You have the right to inspect and copy your protected health information, such as your prescription and billing records. In order to inspect and/or copy your protected health information, you must submit a written request to us. If you request a copy of your prescription or billing information or other records, we may charge you a reasonable fee for the paper, labor, mailing, and/or retrieval costs involved in filing your requests. We will provide you with information concerning the cost of copying your protected health information prior to performing such service. Such requests should be submitted on our Request for InspectionlCopy of Protected Health Information form. Our contact information for such requests is listed on the last page of this document. We will respond within thirty (30) days of receipt of such requests. Should we deny your request to inspect and/or copy your protected health information, we will provide you with written notice of our reasons of the denial and your rights for requesting a review of the denial, if any. In the event of a review, we will select a licensed health care professional not involved in the original denial process to review your request and our reasons for denial. We will abide by the reviewer's decision concerning your inspection/copy requests- Your denial review request should be submitted on our Denial of InspectionlCopy of Protected Health Information form. Copies of these forms are available from the contact person listed on the last page of this document. 3. The Right to Amend or Correct Your Protected health information: You have the right to request that your protected health information be amended or corrected if you have reason to believe that certain information is incomplete or incorrect- You have the right to make such requests of us for as long as we maintain/retain your protected health information. Your requests must be submitted to us in writing. We will respond within sixty (60) days of receiving the written request, unless an extension is necessary, in which case you will be notified, and receive a response to your request within ninety (90) days. If we approve your request, we will make such amendments/corrections and notify those with a need to know of such amendments/corrections. We may deny your request if: a. Your request is not submitted in writing; b. Your written request does not contain a reason to support your request; c. The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment; d. It is not a part of the protected health information kept by us; c. It is not part of the information which you would be permitted to inspect and copy; and/or f. The information is already accurate and complete. If your request is denied, we will provide you with a written notification of the reason(s) of such denial and your rights to have the request, the denial, and any written response (of reasonable length) you may have relative to the information and denial process appended to your protected health information. Your amendmentleorrection request should be submitted on our Request for AmendmenVCotrsection of Protected Health Information form. Copies of these forms are available from our business office. Our contact information for the purpose of making such a request is listed on the last page of this document. 4. The Right to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you may request that we not sand any protected health information to you at a health care facility, but instead send communication for you to a residential address or Post Office Box. We will agree to your request as long as it is reasonable for us to do so. You may submit your requests on our Request for Restriction of Confidential Communications form. Copies of these forms are available from the contact person listed on the last page of this document Our contact information is listed on the last page of this document. I 5. The Right to Request an Accounting of Disclosures of Protected Health Information: You have the right to request that we provide you with a listing of certain disclosures of your protected health information that we have made over a specified period of time. This accounting will not include any information we have made for the purposes of treatment, payment, or health care operations or information released to you, your Privac. Noticc 32 rriva-r coerce family or friends for notification purposes, disclosures made for national security purposes or to certain law enforcement officials, incidental disclosures, disclosures made as part of a limited data set (for use in research, public health, etc.). or any disclosures made pursuant to your authorization. Your request must be submitted to us in writing and must indicate the time period for which you wish the information (e.g., May 1, 2003 through August 31, 2003). Your request may not include releases for more than six (6) years prior to the date of your request and may not include releases prior to April 14, 2003. Your request must indicate in what form (e.g., printed copy or email) you wish to receive this information- We will respond to your request with sixty (60) days of the receipt of your written request. Should additional time be needed to reply, you will be so notified. However, in no case will such extension exceed thirty (30) days. The first accounting you request during a twelve (12) month period will be free. There may be a reasonable fee for additional requests during the twelve (12) month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. You may submit your requests on our Request for an accounting of Disclosures of Protected Health htfornsarion form available from our business office. Our contact information is listed on the last page of this document. 6. The Right to Receive a Paper Copy of This Notice- You have the right to receive a paper copy of this notice even though you may have agreed to receive an electronic copy of this notice. You may request a paper copy of this notice at anytime or you may obtain a copy of this information from our website (as applicable). Our contact information is listed on the last page of this document. Yi. How to File a Complaint About Our Privacy Practices if you have reason to believe that we have violated your privacy rights or our privacy policies and procedures, or if you disagree with a decision we made concerning access to your protected health information, you have the right to file a complaint with us or the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against for fling a complaint. You may submit your complaint on our Privacy Practices Complaint form available from our business office. Our contact information is listed on the last page of this document. 6 Privacy Notice 33 Ammer :Yoltce CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES Record of Ackno lion 7 Faith Effort to Obtain Acknowl/edgmont Name of fResidwiTatieno: Date: Effective Date of This Privacy Nodce'April 14, 2003 Contact information for Questions, Complaints or Requeatt Regarding Your Health Information Should you have any questions conocrning our privacy practices, obtaining a copy of oar privacy notice. requesting restrictions on the release of your information, revoking an authorization, amending or correcting your protected health information obtaining an accounting of our disclosures of your protected health information, requesting inspection or copying of your medical information, requesting that we communicate information about your health matter in a certain way, filing complaints. or any other concerns you may have relative to our privacy practices, please contact: Brian D. Stwalley Chid Compliance 011fter 5775 Allentown Blvd. Suite 202, Harrisburg, PA 17112 Tel: 717-510-1450 Ext. 4, Fax: 717410-1952 bstwalley dtccrx.org if you wish. you may also file a complaint with the Secretary of the U.S. Department of Health and Human Services. You may mail your complaint to U. S- Department of Health and Human Services, 200 hrdependence Avenue, S. W., Washington, DC 20201: or you may call (202) 619-0257 or 1-977.695-1775 (toll free), or you may log on to the internet address, htlp://ws,w.hhs.gov/ocr. Acknowledgment / Good Faith Effort to Obtain Acknowledgment (dreck one of the following) f j I am the above Resident/Patient and I certify that I received a copy of the Continuing Care Rx's Privacy Notice and that l have had an opportunity- to review this document and ask questions to assist me in anderstanding my rights relative to the protection of my health information I am satisfied with the explanations provided to me and I am confident that Continuing Cane Rc is committed to protecting my health information. Date: _ Signature: -- Printed Name: I certify that I am the authorized representative of above name Resident/Patient, and that I have received the Privacy ?Notice on behalf of this individual and that Continuing Care Rr provided me with an opportunity to review this document and ask questions to assist me in understanding the patient's privacy rights. I am satisfied with the explanations provided to me and I am confident that the above-mired entity is committed to protecting he altb information. "_ A Date:, Signature of Representative: Printed Name: Rclationship to Individual: r [ l h• certify that I made a good faith effort to obtain the acknowledgment of the above- identified [rmidcnt/pahentj or hisilw personal representative that he/she had received a copy of the Privacy Notice of Continuing Care Rx, but was unable to obtain such acknowledgment for the following reason(s): ] tRcsidcm/Patientj or personal representative refirsed to sign f ] lResidem/patient] or personal represenative was unavailable to sign. IjOther Date: Signaturef title: Privacy Notice 7 34 • CHURCH CHURCH OF GOD HOME "Committed to Caring" PODIATRY SERVICES I request that payment of authorized Medicare benefits be made either to myself, or on my behalf, to Dr. William Puliq for any services furnished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any information needed to j determine these benefits payable for related services. ,?<Yes, l have accepted Dr. William Pulig as my podiatry care physician ? No, i decline offered podiatry care physician for my podiatry care -,3-//-/ --1 (Date) (Resident/Responsible Party) (Resident Name) (Facility Representative) 35 CMKH OF GOD HOME "Committed to Caring" Privacy Act Statement Healthcare Records This form provides you the advice required by the Privacy Act of 1974. This form is not a consent form to release or use healthcare information pertaining to you. 1. Authority for collection of information including Social Security Number (SSN) Sections 1819 (0,1919 (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. This data is protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records. 2. Principal purposes for which 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 Medicare/Medicaid 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. 36 Privacy Act Statement-Healthcare Records (continued) The information collected will be entered into the Long Term Care Minimum Data Set (LTC MDS) system of records, System #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 Medicare/Medicaid 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 park with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII functions; and (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 Medicare/Medicaid 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. NOTE: Providers may request to have the Resident or their Representative sign a copy of this notice as a means to document that notice was provided. Signature is NOT required. If the Resident or their Representative agrees to sign the form it merely acknowledges that they have been advised of the foregoing information. Residents or their Representative must be supplied with a copy of the notice. This notice may be included in the admission packet for all new nursing home admissions. I (we) acknowledge receipt of the Privacy Act Statement - Healthcare Records -3- /-/ -? ( (Date) 37 &,, (Facility Representa ' ) CHURCH OF GOD HOME "Commirred to Caring" Private Room Policy - Nursing Policy: It is the policy of the Church of God Home that provisions shall be made for isolating a resident in a single room whenever their medical condition requires isolation. Purpose: To ensure that the resident receives the most suitable protection possible. i Procedure: 1. The one private nursing room in this facility may be used as a regular private/single room until the facility's n or isolation room arises. This room is identified as Room 118 Faith Wing. ,? 2. Any resident using rhom 118 must ree on admission that they will move out of the room to a semi-private room if the fad s t0 use it. 3. When a need for an isolation m arises and a semi-private room is not available at Church of God Home, the resident occupying the private room will be transferred as soon as possible temporarily to another long-term care facility until a semi-private room becomes available at the Church of God Home. This individual will then be returned to the private i room when it again becomes available. j 4. Individuals interested in occupying a private room should make their interest known on admission to the Director of Admissions or their Social Worker at anytime. 5. The Director of Admissions will maintain a list of those residents interested in the private room. Such resident will be offered the private room, when available, based on their initial admission date to the Church of God Home, regardless of their level of care or the date they placed their name on the waiting list. 6. When not in an isolation need situation, a resident in the private room must be of private pay status. If no longer able to cover the monthly bill, such resident will be asked to relocate into a semi-private room as soon as an appropriate one becomes available at the Church of God Home. 3-lq-lr (Date) ?I A. I (Resi Bible Party) (Resident Mme) VIA 4111 (Facility Representati 38 F_ 4MQ CHWU OF GOD HOME "Committed to Caring" Therapy Church of God Home has arranged for Genesis Rehabilitation Services, a professional, full-service therapy company, to provide physical, occupational, and speech therapy services. These services will be provided only when the Resident's physician orders them, and when these services are necessary to attain or maintain the Resident's highest practicable physical, mental and psychosocial well being. While the payment of charges for therapy services is the responsibility of the resident, insurance will usually pay for such services. If the resident has Medicare Part B coverage, Medicare Part B will pay for 80% of the therapy charges. The balance of the 20% may be paid by the Resident's supplemental insurance. In the event therapy services are not covered, the Resident will be billed privately. Residents should review the coverage for therapy under their plan, and, if necessary, call the insurance company. Residents I Responsible Party may contact our Business Office with questions related to therapy billing. Th de he?9 co n o the pro ion of therapy services for (the Resident) as ordered by Resident's i8an and deemed necessary to attain or maintain the highest practicable physical, mental and psychosocial well-being. The undersigned understands that no guarantee or assurance has been made as to any result that may be obtained from the Resident's treatment. The undersigned authorizes Church of God Home, Genesis Rehabilitation Services, and the Resident's treating or consulting physicians to release necessary records needed for the provision of therapy services or for payment. (Date) (Resider sible Patty) (Reside Name) (Facility Representative) 39 i I Vaccinations What Is Influenza (Also Called Flu)? The flu is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death . The best way to prevent the flu is by getting a flu vaccination each year. Every year in the United States, on average: 5% to 20% of the population gets the flu; • more than 200,000 people are hospitalized from flu complications; and • about 36,000 people die from flu. Some people, such as older people, young children, and people with certain health conditions (such as asthma, diabetes, or heart disease), are at high risk for serious flu complications. Symptoms of Flu Symptoms of flu include: • fever (usually high) • runny or stuffy nose • headache . muscle aches • extreme tiredness • Stomach symptoms, such as nausea, • dry cough vomiting, and diarrhea, also can occur but • sore throat are more common in children than adults Complications of Flu CompkWdons of flu can include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart falkire, asthma, or diabetes. How Flu Spreads Flu viruses spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may become infected by touching something with flu viruses on It and then touching their mouth or nose. Most healthy adults may be able to infect others beginning 1 day before symptoms develop and up to 5 days after becoming sick. That moans that you may be able to pass on the flu to someone else before you know you are sick, as watt as while you are sick. Preventing Seasonal Flu: Get Vaccinated The single best way to prevent the flu is to get a flu vaccination each year. There are two types of vaccines: • The "flu shot" - an inactivated vaccine (containing kilted virus) that is given with a needle. The flu shot is approved for use in people 6 months of age and older, including healthy people and people with chronic medical conditions. Page i of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PRGYENTION SAFER -HEALTH IMP-PEOPLE° !1 40 Key Fads Abott Sar mal Intim m (Flu) • The nasal-spray flu vaccine - a vaccine made with five, weakened flu viruses that do not cause the flu (sometimes called LAN for 'Live Attenuated Influenza Vaccine'). LAN is approved for use in healthy' people 2-+49 years of age who are not pregnant. About two weeks after vaccination, antibodies develop that protect against influenza virus infection. Flu vaccines will not protect against flu-like illnesses caused by non-influenza viruses. When to Get Vaccinated Yearly flu vaccination should begin in September or as soon as vaccine is available and continue throughout the influenza season, into December, January, and beyond This is because the timing and duration of nfluenza seasons vary. While influenza outbreaks can happen as early as October, most of the time influenza activity peaks in January or later. Who Should Get Vaccinated? In general, anyone who wants to reduce their chances of getting the flu can get vaccinated. However, certain people should get vaccinated each year either because they are at high risk of having serious flu-related complications or because they live with or care for high risk persons. During flu seasons when vaccine supplies are limited or delayed, the Advisory Committee on Immunization Practices (ACIP) makes recommendations regarding priority groups for vaccination. People who should get vaccinated each year are: 1. People at high risk for complications from the flu, Including: • Children aged 6 months until their 5th birthday, e Pregnant women, . People 50 years of age and older, a People of any age with certain chronic medical conditions, and • People who five in nursing homes and other long-term care facilities. 2. People who live with or care for those at high risk for complications from flu, including: • Household contacts of persons at high risk for complications from the flu (see above), • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated), and • Health care workers. 3. Children aged 6 months up to their 1911 birthday 4. Anyone who wants to decrease their risk of influenza. Use of the Nasal Spray Flu Vaccine Vaccination with the nasal-spray flu vaccine Is an option for healthy' people 2-49 years of age who are not pregnant, even healthy persons who live with or cane for those in a high-risk group. The one exception is healthy persons who care for persons with severely weakened immune systems who require a protected environment; these healthy persons should get the inactivated vaccine. I Page 2of3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER - HEALTHIER - PEOPLE" 41 t ? Who Should Not Be Vaccinated Some people should not be vaccinated without first consulting a physician. They include: • People who have a severe allergy to chicken eggs. • People who have had a severe reaction to an influenza vaccination In the past. • People who developed Guillain-Bami syndrome 1GBS1 within 6 weeks of getting an Influenza vine previously. • Children less then 6 months of age (Influenza vaccine is not approved for use in this age group). • People who have a moderate or severe Illness with a fever should wait to get vaccinated until their symptoms lessen. If you have questions about whether you should get a flu vaccine, consult your health-care provider. For more about preventing the flu, see the following: • Key Fads About Seasonal Flu Vaccine • Influenza Antiviral Dn?s • Good Health Habits for Prevention • The Flu: A Guide for Parents "Healthy" indicates persons who do not have an underlying medical condition that predisposes them to influenza complications. For more Information, visit www.cdc.gov/flu, or call CDC at 800-CDC-INFO (English and Spanish) or 888-232-6348 (TTY). Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER-HEALTHIER-PEOPLE- 42 PNEUMOCOCCAL VACCINE POLYSACCHARIDE WHAT YOU NEED TO KNOW VAW vraf.' P. -1 arr. ft w aftw.m. bn *NOR rM ow WIPMgm am waWkwamima " - 71 why get vaccinated? 3 Who should get PPV? Pneumococcal disease is a serious disease that • All adults 65 years of age or older. causes much sickness and death. In fact, pneumococcal disease kills more people in the - Anyone over 2 years of age who has a long- United States each year than all other vaccine- term health problem such as: preventable diseases combined. Anyone can get - heart disease pneumoeoccal disease. However, some people are - lung disease at greater risk from the disease. These include - sickle cell disease people 65 and older, the very young, and people - diabetes with special health problems such as alcoholism, - alcoholism heart or lung disease, kidney failure, diabetes, H1V - cirrhosis infection, or certain types of cancer. - leaks of cerebrospinal fluid Pneumococcal disease can lead to serious infections of the lungs (pneumonia), the blood (bacteremia), and the covering of the brain (meningitis). About 1 out of every 20 people who get pneumccoccal pneumonia dies from it, as do about 2 people out of 10 who get bacteremis and 3 people out of 10 who get meningitis. People with the special health problems mentioned above are even more likely to die from the diease. Drugs such as penicillin were once effective in treating these infections; but the disease has become more resistant to these drugs, making treatment of pneumoeoccal infections more difficult. This makes prevention of the disease through vaccination even more important. Pneumococcal polysaccharide 2 vaccine (PPV) The pneumoeoccal polysaccharide vaccine (PPV) protects against 23 types of pneumococW bacteria Most healthy adults who get the vaccine develop protection to most or all of these types within 2 to 3 weeks of getting the shot. Very old people, children under 2 years of age, and people with some long-term illnesses might not respond as well or at all. Anyone over 2 years of age who has a disease or condition that lowers the body's resistance to infection, such as: - Hodgkin's disease - lymphoma, leukemia - kidney failure - multiple myeioma - nephrotic syndrome - HIV infection or AIDS - damaged spleen, or no spleen - organ transplant Anyone over 2 years of age who is taking any drug or treatment that lowers the body's resistance to infection, such as: - long-term steroids - certain cancer drugs - radiation therapy • Alaskan Natives and certain Native American populations. Pneumo=cal Polysaccharide 43 4 How many doses of PPV are Q needed? Usually one dose of PPV is all that is needed. However, under some circumstances a second dose may be given. A second dose is recommended for those people aged 65 and older who got their first dose when they were under 65, if 5 or more years have passed since that dose. • A second dose is also recommended for people who: have a damaged spleen or no spleen - have sickle-cell disease - have HIV infection or AIDS have tanner, leukemia, lymphoma, multiple myektma have kidney failure have nephmtic syndrome have had an organ or bone marrow transplant are taking medication that lowers immunity (such as chemotherapy or long-term steroids) Children 10 years old and younger may get this second dose 3 years after the first dose. Those older than 10 should get it 5 years after the fast dose. 5 Other facts about getting the vaccine • Otherwise healthy children who often get or infections, sinus infections, or other upper respiratory diseases do not need to get PPV because of these conditions. • PPV may be less effective in some people, especially those with lower resistance to infection. But these people should still be vaccinated, because they are more likely to get seriously ill from pttettmococal disease. • Pregnancy: The safety of PPV for pregnant women has not yet been studied. There is no evidence that the vaccine is harmful to either the mother or the fetus, but pregnant women should consult with their doctor before being vaccinated. Women who are at high risk of pneumococal disease should be vaccinated before becoming pregnant, if possible. fi What are the risks from PPV? PPV is a very safe vaccine. About half of those who get the vaccine have very mild side effects, such as redness or pain where the shot is given. Less than 1% develop a fever, muscle aches, or more severe local reactions. Severe allergic reactions have been reported very rarely. As with any medicine, there is a very small risk that serious problems, even death, could occur after getting a vaccine. Getting the disease is much more likely to cause serious problems than getting the vaccine. 7 What if there is a serious reaction? What should I loot for? • Severe allergic reaction (hives, difficulty breathing, shock). What should I do? • Call a doctor, or get the person to a doctor right away. • 1kU your doctor what happened, the date and time it happened, and when the vaccination was given. • Ask your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you an file this report through the VAERS web site at www.vam.org, or by calling 1-800-822-7%7. VAERS does not provide medical adt»ce. $ How can 1 isarn more? • Ask your doctor or nurse. They an give you the vaccine package insert or suggest other sources of information. • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): - Call 1-800.232-4636 (1-800-CDC-INFO) or - Visit the National Immunization Program websire at www edc.gov/vaccines 'r M2 tKPAat r"KXT OF NBALTN AND HUMAa1 IQ f CENTER. FOR DISEASE CONTROL AND PREVENTION Pneamoeoeeat Vaccine Inkn=dm Statement 44 4mb? CHURCH OF GOD HOME Tommitird to Carina" Vaccinations The Church of God Home administers flu vaccine on an annual basis for all residents of our facility. Annually the Tri-Valent Influenza Vaccine will be offered, prior to the beginning of flu season, for all residents who provide written authorization themselves or by his/her responsible party. A resident cannot receive the Td-Valent Influenza if they are allergic to eggs or egg products. Otherwise, the Tri- Valent Influenza has proven to be generally safe and effective. If you desire to receive the Tri-Valent Influenza vaccine and/or the pneumonia vaccine, please complete the authorization below. ? I do authorize that the Tri-Valent Influenza vaccine be given annually per facility protocol. ? No, I do not wish to receive the Tri-Valent Influenza at any given time. ? I have received literature pertaining to the benefits of the Tri-Valent Influenza vaccine. i The Church of God Home also offers a vaccine that provides effective protection against the Pneumococcal form of pneumonia. This vaccine will be available to those residents who desire it and are medically eligible. If you have any questions, you may discuss them with your personal physician r the Church of God Home physician who monitors your care. ? I do authorize that the Pneumococcal Pneumonia vaccine be given. ? No, I do not wish to receive the Pneumococcal Pneumonia vaccine at any given time. ? 1 have received literature pertaining to the benefits of the Pneumococcal Pneumonia Vaccine. If known, please indicate the date when the vaccines listed below were last received: Tri-Valenflnfluenza vaccine: Pneumonia Vaccine: Tetanus Vaccine: A-161-11 (Date) 45 (ResidentlResponsible Party) 4mb? MIRCH HOME "Committed to Caring" Valuables The Church of God Home desires to administer quality care for all of our residents, focusing on a high quality of life. We do want to avoid any unfortunate situation that could result in any financial or emotional loss to residerts and/or families. Our Horne has not had many such losses, but when they happen, it is tragic. To m0mize the risk of loss, the Church of God Home recommends that residents have no more than five dollars IT-9 )`et any one time in their possession or rooms, and keep no valuables, real or intrinsic, in their moms. By signing 1:61i paper you acknowledge being informed of the Home's recommendations. Some people have wisely substituted `zircons for diamonds and kept the settings. It is the responsibility of the resident or the responsible party to hav? items of value independently appraised and insured, if so desired to cover potential damage to or loss of personal property. If damage or loss occurs to the resident's property, the Church of God Home will investigate each incident of loss or damage to determine liability and assess depending on the facts and circumstances of each incident. The Church of God Home shall be responsible for only such losses or damages as are attributed by the Home due to the negligence of the Home. (Date) (Residen sible Party) (Resident N V-, K (Facility Representative) 46 CHURCH OF GOD HOME, INC. ADMISSION AND RE AGREEMEN THIS AGREEMENT is made on this day of , 20_U, by and between the Church of God Home, Inc., called the "Facility," a Pennsylvania n fit n I t t 001 No rth Hanover Street, sle, I?mbe d Penns vania, and called "Resident" and called "Responsible Party". The Resident and the Responsible Party reaffirm that the information provided in the Pre-Admission Questionnaire is true and correct and understand that the submission of false information may constitute grounds to terminate this Agreement. The Resident has applied for admission to the Facility and the Facility has approved the Application for Admission. Therefore, the Facility and the Responsible Party agree to the following terms: 1. PROVISION OF SERVICES - The Facility will provide Resident with: a. Skilled nursing care, i.e. professionally supervised nursing care and related health services under a plan of services regularly provided under a plan of care supervised by licensed personnel and, as required by the Resident's medical condition, assistance with activities of daily living. b. Accommodations consistent with the level of cane provided to the Resident including heat, air conditioning, electricity, hot, and cold water. c. Bed, bedding, blankets, laundered bed linens, towels, and washcloths. d. Three meals each day except as otherwise medically indicated. e. Activity programs, Spiritual programs, and Social Services. 2. RECURRING CHARGES - In exchange for the above services, the Resident shall pay the following recurring charges: cG a. For skilled nursing care: $? dollars per day. 3. SECURITY DEPOSIT - The Resident shall pay the following non-recurring charges: a. A security deposit in the amount of thirty-one (31) times the current daily rate for the level of care required by the resident, will be billed after admission day. The amount of the security deposit is silLr. No interest will be paid on the security deposit. A security deposit will not be charged to re idents who are receiving benefits for room and board provided by Medicare, until the Medicare benefit concludes. An applicant who is covered by Medicaid is not required to pay a security deposit, b. If the admission to Nursing Care is the result of a level of care change from Personal Care, the Resident will be billed the difference between the two Security Deposit rates. c. The security deposit for private pay residents, after deductions for the payment of any outstanding bills owed to the Facility, will be refunded within thirty (30) days after the Resident's discharge or death. Upon discharge or death the following refund policy will be followed: i. Thirty (30) days - Private Pay ii. Ninety (90) days - Medicaid iii. Thirty (30) days - Personal Cash Account There will be no other refunds, in the absence of an over payment, under this Agreement. 4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES - Resident is responsible to pay for other services provided by the Facility, which are not covered by the daily rate/charge. A list of such services charges is attached to this Agreement on the "Chart of Costs." 47 Admission and Care Agreement- continued The services of a licensed physician and dentist, a registered pharmacist and licensed pharmacy for the provision of pharmaceutical supplies, a licensed hospital, and diagnostic services, will be made available at the Resident's expense. The resident has the right to select his/her own physician or any other service provider so long as the physician or other service provider is property licensed or registered under the law, and that all applicable government rules and policies of the Facility are met. In addition to the Facility's charges, the Resident is responsible to pay all fees and costs for goods or services furnished to or for the Resident by anyone other than the Facility under this Agreement. The responsibility of the j Resident to pay applies to all fees for costs of services provided for the Resident by any physician, dentist, optometrist, therapist, diagnostic or resting laboratory, pharmacist, pharmacy, hospital, or any other person, facility or entity providing services or goods to or for the Resident, and for all drugs, medicines, medications, pharmaceutical supplies, corrective eye lenses, hearing aids, dentures, hair care, and other personal items or services for the Resident. Such fees and costs are not included in the Home's daily rate/charge. 5. ADMISSION - The Resident will be admitted, or a bed will be reserved for Resident, beginning on _3 q - I( , All pre-admission charges will be billed after admission, and recurring charges will begin to' accrue as of the above date. The Resident may reserve an available bed by paying the daily rate for the bed reserved. The daily rate for the reserved bed will continue to accrue and be payable until the reservation is terminated, even if the Resident does not enter the Home for whatever reason, including illness, injury, incapacity or death. 6. PERIODIC BILLINGS AND PAYMENT DUE DATE a. On the first of each month, Resident will be billed the current daily rate for Resident's current level of care times the number of days in the month. The bill is due and payable upon receipt. A service charge of one and one-half (1 Y2%) percent per month will be added to amounts past due in excess of thirty (30) days, and Resident, and if applicable, Responsible Person or Guarantor is obligated to pay any late charges. b. Miscellaneous charges (refer to "Chart of Costs' attached to this Agreement) such as hair care, personal laundry, incontinency, supplies, etc., are additional charges above the daily rate. These miscellaneous charges will be added to, and included with, your monthly bill. c. Pharmacy changes will be billed as a separate part of the Facility's monthly bill, and will require a separate check, d. Outside providers will bill directly and separately. 7. CHANGES IN CHARGES- From time to time, the Facility may change the amount of its charges. In addition, from time to time, the Facility may change how and when its changes are computed, billed or become due. The Facility reserves the right to make any such changes at any time. Written notices of any such changes will be given to the Resident thirty (30) days in advance of implementation, unless the change is required earlier under any federal or state law or assistance program. 8. "MEDICAREIMEDICAID" PROGRAM - The Facility participates in the Medicare program administered pursuant to Title XVIII o f the Federal Social Security Act and the Medicaid (Medical Assistance) Program administered pursuant to the Pennsylvania state plan and Title XIX of the Federal Social Security Act. However, the Facility reserves the right to withdraw from the Medicare/Medicaid program at any time in accordance with the law. 48 Admission and Care Agreement- continued 9, OBLIGATIONS OF RESPONSIBLE PARTY - The Responsible Party is responsible for services and supplies that are billed through the Facility directly to the Resident, Responsible Party, or by any other provider. The Responsible Party is responsible to pay all fees and costs from Resident's resources. In the event of an emergency the Responsible Party is asked to leave an emergency contact telephone number (s). (i.e. when vacationing) 10. READMISSION - BED HOLD POLICY - If the Resident leaves the Facility for a period of hospitalization, therapeutic leave, or any other reason, other than the Resident's death, and if the Resident is not eligible for, or receiving medical assistance, the Responsible Party will be contacted to determine is the bed is to be held in reserve at the daily rate. If the Resident or Responsible Party elects not to reserve a bed, then the Resident will be eligible for readmission upon the availability of the first bed suitable for the Resident's level of care. If the resident is receiving medical assistance benefits and the Resident leaves the Facility for a period of hospitalization or therapeutic leave, the Resident's bed will be reserved for the applicable maximum number of days paid for the reserved bed under the Medicaid (Medical Assistance) Program. The current bed reservation period is fifteen (15) days for hospitalization, fifteen (15) days for therapeutic leave for residents receiving skilled nursing care, and thirty (30) days for therapeutic leave for residents receiving nursing care. The bed reservation period may be subject to change in accordance with any changes in the Medicaid (Medical Assistance) Program. If the period of hospitalization or therapeutic leave ends within the reservation period under the Medicaid (Medical Assistance) Program, the Resident may return to the Facility. If the period of hospitalization or therapeutic leave exceeds the maximum time for reservation of a bed under the Medicaid (Medical Assistance) Program, the Resident must wait until a suitable bed becomes available for readmission. The Resident is entitled to the first available bed suitable for the Resident's level of care if, at the time of readmission, the Resident requires the services provided by the Home. Effective May 30, 2008, Medicare requires that each resident / responsible party indicate their choice with regard to a bed hold if any nursing resident is hospitalized. ? Yes, I would request a bed hold. I understand that I will be billed at the standard daily rate. ? No,1 not wish to hold a bed in the event of a hospitalization. I understand that by doing be bed may no be available for readmission. o be determined at time of hospitalization. 11. REFUNDS - The security deposit for private pay residents, after deductions for the payment of any outstanding bills owed to the Facility, will be refunded within thirty (30) days after the Resident's discharge Facility or death. Residents receiving Medicaid will receive a refund, if any due, within ninety (90) days. There will be no other refunds, in the absence of an overpayment, under this Agreement. 12. PERSONAL FINANCES - The Resident has the right to manage his/her personal funds. The Resident is and will be responsible to provide his/her personal funds. If the Resident elects, the Resident may designate, in writing, that the Facility hold and manage the Resident's personal funds. If the Resident designates someone other than the Facility to manage his/her personal funds, the Resident or Responsible Party shall notify the Facility promptly. The Resident is not required to make any designation, and is responsible for his/her own personal funds unless such designation is made. 49 Admission and Care Agreement- continued The Resident may revoke, at any time, the designation of the Facility as the manager of his/her personal cash account by providing the Facility a written notice signed and dated by the Resident or Responsible Party. If the Resident transfers to the Home, responsibility to manage the Resident's personal funds, the Facility will do so in accordance with the "Rights of Nursing Facility Residents", a copy of which is provided at the time of your admission. The Facility may deduct, at any time, charges due the Facility under this agreement from the Resident's personal funds managed by the Facility. 13. TERMINATION, TRANSFER, DISCHARGE, OR LEAVE OF ABSENCE a. By the Resident: The Resident may terminate this Agreement upon thirty (30) days written notice to this Facility. If the Resident leaves the Facility for any mason other than a medical emergency or death, the Resident must give written notice to the Facility at least thirty (30) days in advance of the departure/transfer/discharge or termination of the Agreement. If advance written notice is not given to the Facility, there will be due to the Facility it's daily and other changes then in effect for the Resident's current level of cam for the required thirty (30) day notice period. The charge applies whether or not the Resident remains at the Facility during the thirty (30) day period. b. By the Facility: The Facility may terminate the Resident's stay and transfer or discharge the Resident if: i. The transfer or discharge is necessary to meet the Resident's welfare which cannot be met by the Facility; ii. The Resident's health or condition has improved sufficiently that the Resident no longer needs the services provided by the Facility; iii. The safety or health of individuals in the Facility is or otherwise would be endangered; iv. The charges or other amounts due the Facility under this Agreement have not been paid to the Facility or treated as paid to the Facility on the Resident's behalf the Pennsylvania Medicaid Program or Federal Medicare benefits under Title XVIII or v. The facility ceases to operate. The Facility generally will notify the Resident and Responsible Party or if none, a family member of legal representative of the Resident, if known to the Facility, at least thirty (30) days in advance of such a transfer or discharge. However, in any case, described in subparagraph (i), (ii) or (iii) above, or if the Resident has not resided at the Facility for at least thirty (30) days, the Facility will give such notice before transfer or discharge as is practicable under the circumstances. 50 Admission and Care Agreement. continued 14. THIRD PARTY PAYMENTS - The Resident may be or may become eligible to receive financial assistance, reimbursement or other benefits from third-parties, such as through private insurance, employee benefit plans. Medical assistance under the Pennsylvania Medical Assistance Program, Medicare benefits, supplementary medical or other health insurance, supplemental security income insurance, or old age survivors' or disability insurance under or pursuant to the Federal Social Security Act or Program. If the Resident becomes eligible to receive payments from any third-parties for the stay and care of the Resident, the Resident/Responsible Party shall, at all times, cooperate fully with the Facility and each third-party payments. Cooperation includes, when requested, providing information, signing and delivering documents, and having the Facility designated by the Social Security Administration as the Resident's representative payee for receipt of Federal Social Security benefits or any other governmental assistance, reimbursement or benefits to the extent of all charges due the Facility. The Resident irrevocably authorizes the Facility to make claims and to take such other actions as maybe necessary for the Facility's receipt of third-party payments. To the fullest extent permitted by law, the Resident hereby assigns now or hereafter payable to the extent of all charges due to the j endorse and turn over to the Facility any payments received from third-parties to the extent necessary to satisfy the charges under this Agreement. 15. PERSONAL PROPERTY- The Resident/ Responsible Party is and will be responsible to furnish and maintain clothing, jewelry, personal possessions, and other items of property. The faciNty may limit the amount or type of property that the Resident may keep at the facility if there is insufficient space, or if medically indicated or necessary to protect the rights or welfare of others. All non-clothing items of value must be recorded on the resident's personal inventory located with their medical record on the day of admission or any day thereafter. The same is true if removing an item of value from the resident's room. You are requested to see the charge nurse / social worker regarding resident's personal property. If clothing needs labeled, please leave them at the nursing station. 16. RESPONSIBILITIES OF RESIDENT- The Resident shall comply fully with all governmental laws and regulations, the provisions of this Agreement and the facility's existing policies, rules and regulations which may, from time to time, be altered or amended. 17. MISCELLANEOUS PROVISIONS a. The Resident and Responsible Party acknowledge that they are adult individuals and have read and understand the terms of this Agreement. b. The provisions of this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania and shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigned. c. The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by competent legal authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been part of this Agreement. 51 Admission and Care Agreement- continued d. The Facility reserves the right to modify unilaterally the terms of this Agreement to conform to subsequent changes in the law or regulation and changes in charges. Resident will be provided thirty (30) days written notice of changes in charges and, if practicable, reasonable notice of any modifications required by law. (Date) (ResidentlResponsible Party) c (Resident N S (Facility Representative 11 52 RESIDENT / FAMILY GUIDE TO INQUIRIES AND INFORMATION i 0 c '- p 7a m d ev Inquires 9 I ? a c 0 a c; r I " L. c -a a .5 a" c" a ' 0 ? ° c ? 19 ? 3IE m mom M I ?. Q i xtn m0 U U_ 02 2 ? z0 trxQ ym >p Healthcare Personal Care X Admissions Independent Living X Admission Billing Question X Medicare X Question Applying for x Medicaid Pharmacy Billing X Laundry Billing X Donation Monetary X Donation Other X Personal Cash Account X Questions Personal Cash Deposits/ X Withdrawals Guest Meal i Reservations x Party i Reserving of Lounge X Family Concems X ' HIPPA Changes X Coordinate Change in Level of Care X Resident Lost Items X Telephone Cable X Hook-up LeTort X Guest Suite 53 RESIDENT I FAMILY GUIDE TO INQUIRIES AND INFORMATION t o ? c eo 'io a ?2 a co, E cC= ?- `° A V c ? ? c ? ? c n a.. W g ' M r e .. m m p p _ 7L h Inquires E t °?, .? E N 010 0 o: 2w z c >o I I W o a xw mo U Change in Laundry Service x Transport Requests x X Special Hair Care Requests, Payment Scheduling X Resident Care X Resident Medication I X Physician Questions X Therapy Questions X Taking Residents Out of Facility X Change in POA Contact X Address /Phone Change in POA X Health Insurance Cards X Religious Questions X Funeral Questions X Funeral Procession Service X ! Memorial Services X The Orchards" at Marsh Run x 54 Facility Mailing Address: Facility Main Telephone #: 801 North Hanover Street Carlisle, PA. 17013 (717) 249-5322 "Raw Facility Administrator: .................... Susan Bower, NHA ................................................................ ext. 3086 Activity Dept.: ? ........ ..Amy Findon, CTRS ................................................................. ext. 3021 -- -`'?, (Director of Activities) Business Offs ............. Sharon Cramer (Business Office / Henderson House)........................ ext. 3032 ; (Sr. Billing AIR Specialist -Personal Cash Accounts) „,_ ? ..............Michele Shughart (Business Office I Henderson House) ...................... ext. 3095 ` (Billing Specialist - Medical Assistance) - '- -? Cate Plan:? ..............Lynne Shellenberger, RN (Mtg. win 14 days of Admission C..ext. 3033 (Nursing Assessment Coordinator - RNAC) Chaplain: ? ............. Pastor Bradley Moore............................................................. ext. 3022 Dietafy: ? .............. Bradley Weiser....................................................................... ext. 3966 (Director of Dining Services) Hair Care: ? .............. Joan Ludwig ......................................... .............................. ext. 3003 (Director of Hair Care) Medical Appts.: ? .............. Dava Beltz .............................................................................. ext. 3961 (Nursing Administrative Assistant) Nurs-F-7 --? ......... Mary Hartman, RN, BSN ........................................................ ext. 3015 (Director of Nursing ?.. Faith Long Hall (#103-116) .................................................. 3 ? .............. Faith Short Hall (#99,100-102,117-126) ...................................... ext. 3010 ? .............Love l (#201-215)...................................................................... ext. 3024 ? .............. Love 1/ (#217-239) ..................................................................... ext. 3025 ? .............. Beth Thumma, LPN................................................................ ext. 3012 (Personal Care Administrator), (Hope, Peace and Creekside Apt.) Pharmacy: ? ............. htinuing Care RX..................................................... 1-800-675-2279 Social Services: ............ Erin Naylor, MSW ............................................................. !ext. 3084 l (Director of Social Services) ? .............. Ellen Myers, BSW................................................................... ext. 3023 (Social Worker) Therapy Dept.: ? .............. Genesis Rehabilitation Services ............................................. ext. 3017 Volunteer Office: ? .............. Linda Waggoner..................................................................... ext. 3028 (Director of Volunteers) Physic Telephone: 56 Checklist - Nursing Care 1- 1. CO LETFJ COPY: ADVANCED DIRECTIVES/(gtq, , -LNG-TERM. CARE INSURANCE POLICY MBULANCE CARD W?' RD Ate.. OF 'TORNEY AGK HURCH OF GOD HOME, INC. UfW SHEET. . INSU CARDS VERIFIED MMERE UPPLEMENTAL ? RX ? OTHER 1 56 2. REVIEW AND INFORM: ADMISSION AND CARE AGREEMENT ADMISSIONS POLICY ADVANCE DIRECTIVE POLICY AMBULANCE CHART OF COSTS COMPLAINT PROCEDURE DELEGATION FORM DEPLETED FUNDS DIETARY SERVICES DVD ACKNOWLEDGEMENT GUEST ROOM LEGAL RIGHTS COMPLIANCE MEDICAID MEDICARE MISSIONNISION STATEMENT NON-DISCRIMINATION STATEMENT PERSONAL CASH ACCOUNT PERSONALLAUNDRY LSECURITY CARD ACCINE INFORMATION FORM ? 0TH TO BUSINESS OFFICE COPIES TO DEPARTMENTS ? COPY-TO RESIDENT [-COPY TO RESPONSIBLE PARTY PHARMACY AGREEMENT PODIATRY PRIVACY ACT STATEMENT PRIVATE ROOM POLICY PSYCHIATRIST RESIDENT/ FAMILY GUIDE RESPIRATORY CARE SMOKING POLICY SPECIALIZED SERVICES SPOUSAL RESOURCE ASSESSMENT THERAPY SERVICES TRANSPORTATION UNDERSTANDING RESTRAINT USE VALUABLES WELCOME DIRECTORY WELCOME LETTER X-RAY ? OTHER I acknowledged that I have received the above information and have been afforded the opportunity to ask questions. -3_/!?(_U (ReLide*?spoi]sible Party) (Date) EXHIBIT "C" (TO COMPLAINT) Notice ID: 9006348598 CUMBERLAND CAo B wE TIYIINSTER DRIVE CARLI LE, PA?70?3-9978 Pennsylvania J--PAR 7 MEN 1' 0) Nv9LTC: WEL?A,RE Mali Date: 11!29/2011 OFFICE OF INCOME MAINTENANCE Record ID: 21/0163127 Telephone: 1-800-269-0173 CHURCH OF GOD HOME Notice ID: 9006348598 801 N HANOVER ST COMPASS: The fast and easy way to apply for benefits CARLISLE, PA 17013-1599 www.com2a88.ata*• na asQ AiLEt? e,I rM IS D T- I T 1Tj t 5 i t«C a DEAR CHURCH OF GOD HOME, You have been designated to receive a copy of notice on behalf of Ruth ubin (850285141). Please read further for details. Which benefit? This is a summary of your benefits. You can find more information inside this letter. Medical Assistance Your eligiblity for benefits has been reviewed and you do not qualify for Medical Assistance because the values your resources is too high . Read this letter for more m&-r-maWon. If you do not agree with this decision, read the flier that came with this letter called "Your Right to Appeal and to a Fair Hearing." Fill out the Fair Hearing form, then main it or give it to your caseworker by December 29, 2011. Long Term Care You do not qualify for payment of services in a Long Tenn Care facility because the value of your resources is too high - Read this [after for more information, If you do not agree with this decision, read the flier that came with this fetter called "Your Right to Appeal and to a Fair Your benefft Information is continued on the next page.. If you have a disability and need this letter in large print or another format, please call our helpline at 1-800-692-7462. TDD Services are available at 1-800-451-58861. If you do not agree with our decision, you have the right to a Fair Hearing. To learn more about Fair Hearings, read Your Right to Appeal and to a Fair Hearing. Do you need legal help? You can get free legal help by visiting: MIDPENN LEGAL SERVICES at 401-405 LOUTHER STREET, CARLISLE, PA 17013 or by calling (717) 243-9400. Record ID: 21/0163127 Mail Date: 11/2)/2011 Page 1 of 8 PA 152 *900634859830000104* Notice ID: 9006348598 Which benefit? This is a sununary of your beneft. You can fired mare intmat on inside this tatter. Hearing." Fill out the Fair Hearing farm, then mail it or give it to your caseworker by December 29, 2011. Record ID: 2'610163127 Mail Date: 11129/2011 Page 2 of 8 PA 162 Notice ID: 9006348598 Your Medical Assistance Benefits 0 Who dues not qualify? Who? RUTH When? July 01, 2011 - July 31, 2011 This is the law we used to make this decision: 55 Pa. Code § 178.1 RUTH: (.07/01/2011-07/31/2011) Your countable resources are over the resource limit. If you do not agree with this decision, read the flier that came with this letter called "Your Right to Appeal and to a Fair Hearing," Fill out the Fair Hearing form, then mail it or give it to your caseworker by December 29, 2011, .. Lang Term Care Who dmw not qu?1ltfy? Who? RUTH When? July 01, 2011 - July 31, 2011 This is the law we used to make this decision: 55 Pa. Code § 178.1 RUTH: (07/01/2011-07/31/2011) You do not qualify for payment of services in a Long Term Care facility because you do not qualify for Medical Assistance. If you do not agree with this decision, read the flier that came with this letter called "Your Right to Appeal and to a Fair Hearing." Fill out the Fair Hearing form, then mail it or glue it to your caseworker by December 29, 2011. Record ID: 21/0163127 Mail Date: 11/29/2o11 Page 3 of 8 PA 162 '900634859830000204• Notice ID: 9006348598 Record ID: 21/0163127 Mail Date: 11/29/2011 Page 4 of 8 -l82 Notice lD; 9006348598 Your Right to Appeal and to a Fair Hearing What does right to appeal mean? Your right to appeal means that you have the right to ask us to review our decision, if you think that we made a mistake. You can ask us to review our decision at a fair hearing. What Is a fair hearing? A fair hearing Is a meeting where you, the county assistance office (CAO), and a judge can talk about your appeal. How can you ask for a fair hearing? You can call the CAO to ask for a fair hearing if you get a letter telling you about a decision that you think is wrong, if the decision is for Cash Assistance, Medical Assistance, Low Income Home Energy Assistance Program (LIHEAP) or State Supplementary Payment (SSP), you must also complete the attached Fair Hearing Form. If the decision is for SNAP (Food Stamps) fill out the fort and send It to us. You do not have to do this, but It's easier for us to track your appeal if you do. When can you ask for a fair hearing? You can ask for a fair hearing 11- • you apply for benefits and you get a letter saying you do not qualify, or • you get a letter saying that your benefits will stop or change, or • you do not agree with the amount of your benefit. Do you need legal help? You can get free legal help by visiting MiDPENN LEGAL SERVICES at 401-405 L.OUTHER STREET CARLISLE, PA 17013 or by calling (717) 243-9400. x, 1. Choose the kind of fair hearing you want: Call the Statewide Customer Service Center at 1-877-395-8930. In Philadelphia, call 1-215.580-7226. The call is free. Call Monday to Friday from 8 a.m. to5p.m. • A telephone hearing at a place you choose. Tell us which phone number to use, such as your own, or a friend or relative's phone number. If you choose this kind of hearing, make sure we can reach you at this phone number. The judge will call you and everyone In your case, such as your witnesses, anyone helping you, and the county assistance office (CAO). • A telephone hearing at the CAO. You will go to the CAO for your hearing. ?• The judge will call you there in the office, and call anyone helping you. • A face-to-face hearing with everyone in the hearing room. You can choose to have your hearing in Erie, Harrisburg, Philadelphia, Pittsburgh, Plymouth, or Reading. t~ The judge, you, CAO staff, witnesses and anyone helping you will be in the room. • A face-to-face hearing with some people in the hearing room and some people on the phone. You can choose to have your hearing in Erie, Harrisburg, Philadelphia, Pittsburgh, Plymouth, or Reading. t? You and anyone helping you will be in the hearing room with the judge. The CAO staff will be on the phone. PA)FS 162 F 2/10 Record ID: 2110163127 Mail Date: 11129/2011 Page 5 of 8 *900634859830000304* Notice ID: 9006348598 2, Fill out the form on the last page. 3. Mail the form to: CUMBERLAND CAO, 33 WESTMINSTER DRIVE • 3 CARLISLE, PA 17013-9976 or give this form to the CAO. Call the Statewide • For Cash Assistance, Medical Assistance, or SS.P, you must mail or give the form Customer Service to the CAO within 30 days of the mailing date on your letter. Center at • If you are applying for SNAP and you do not agree with the decision, you must 1-877-395-8930• mail or give the form to the CAO within 90 days of the mailing date on your letter. • If you already get SNAP and you do not agree with the decision, you must mail or give the In Philadelphia, call form to the CAO within 90 days of the first day of the month that, y Your benefits change. 1-215-5$0-722$ • For LiNEAP you must mail or give the form to your CAO within 30 days of . the mailing date on your letter. The call is free. Call Monday to Got mdy for a. h4aring Friday from 8 a.m. to 5 P.M. Can you talk with us before the fair hearing? Yes. You will get a letter from the CAO asking if you want to meet before the fair hearing takes place. A meeting before the hearing is called a pre-hearing conference. This meeting will not delay or replace your fair hearing. Remember: You can use this meeting to tell us If you have information that you think might change our You must ask for i decision. You can bring someone to speak for you if you want to. fair hearing within Can you get a copy of any information we used to make our decision? 13 days of the mailing date on Yes, you can ask for a copy of all the documents that will be used at the hearing. your letter, if you Who can come to the hearing? want your benefits You can bring anyone to the hearing, such as witnesses who might have information. You to stay the same can speak for yourself or bring someone to speak for you who knows more about the rules of while you wait for the program. your hearing. What If you speak another language, are deaf or have another d1sab0ity? ' You can ask for an interpreter or other assistance to be at the fair hearing on the attached Fair Hearing Form. This is a free service. You may bring a friend or relative to help you at the hearing, but the Department will provide the official interpreter. At the Hearing What happens at,a fair hearing? 1. The CAO will tell you and the judge how they made their decision. You may ask questions. 2. You will have time to tell the judge your side of the case. Someone can speak for you (if you want), and your witnesses can speak. You may show documents to the judge. 3. The judge may ask questions. When will you know what the judge decides? The judge will send you the decision within 90 days (within 60 days for SNAP (Food Stamps)) of the day you asked for the hearing. What happens if the judge decides the CAO is right? If the judge decides that the CAO made the right decision, your benefits will change or stop. ? You may have to pay back some or all of the benefits you got while waiting for your hearing. What If you do not agree with the judge's decision? You can appeal again. The judge's decision letter will tell you how to appeal. Record ID: 21/0163127 Mail Date: 11!29!2011 Page 6 of 8 Notice ID: 9006348598 Fair Hearin Form 1. Name: CHURCH OF GOD HOME Case Number: 2110163127 Phone number: Address: 801 N HANOVER ST 111 1 ? 1114q -SKIP CARLISLE, PA 17013-1599 2. Tell us which program you want to appeal: ? Other 3. Choose the way you want your hearing: ,Z By telephone, at the phone number you write on this form ? By telephone, at the CAO. ? Face-to-face, with CAO staff and a judge in the hearing room. ? Face--to-face, with you and the people you bring in the hearing room with a. judge and CAO staff on the phone. 4. Do you need a free Interpreter? ? Yes ZNs ueetions Call the Statewide Customer Service Center at 1-877-385-8930. In Philadelphia, call 1-21S460-7226. The call is free. Cats Monday to Friday from 8 a.m. to 5 P.M. R yes, what language? 5. If you will need help at the appeal because of a hearing Impairment or other disability, please tell us how we can help you. There is no cost to you for this service. 6. Tell us why you 7. Signature: 8. Date: r 9. Representative Name: gy-rao - I I [ C_tr 6 R ? 10. Representative Address: i , V'15 r)m 11. Representative Telephone Number:-1y1- L'4Q'-6 J? The Bureau of Hearings and Appeals will send you a letter to tell you when ardl where your hearing will be. PNFS 182 F 7110 rn*01 ?• 1 As. Record ID: 21/0163127 tv all Date: 1112912011 Page 7 of 8 *9006348598300oD404' EXHIBIT 44D9'5 (TO COMPLAINT) out vi neann s-Hppeais 2330 Vartan Way Second Floor Harrisburg PA 17110-9946 NOTICE OF HEARING DATE AND TIME Ivana Grujic Schufjer Bo gar 309 Fellowship Rd Suite 200 Mt Laurel NJ 08054 • penn*17.y is DEPARTMENT OF PUBLIC WELFARE EWreau of Hearings & Appeals Phone: (717) 783-3950 Fax: (717) 772-2769 Gate February 23, 2012 Appellant Name and Address: Ruth C. Aubin Church Of God Home 801 N Hanover St Carlisle PA 17013 Case No: 210163127-001 RE: NOTICE TYPE: PA/FS 162F DATE OF NOTICE: 11/29111 Dear Ms. Aubin: NOTICE ID: 9006348598 This acknowledges your request for a fair hearing from a decision by the Cumberland CAO concerning Nursing Home Denial, All Actions. A telephone hearing has been scheduled for you. The Administrative Law Judge will call you at the telephone number you provided on your appeal at the date and time specified below. Please notify my office immediately if this number has changed or is incorrect, or if you want a face-to-face hearing in Harrisburg. Hearing Date: March 14, 2012 Time: 10:00 a.m. You will be called at: (856) 533-2464 Administrative Law Judge (ALJ): C Michael Lane 'IMPORTANT: If you, or a representative for you, is not available for the hearing, you will lose the case. If, before the hearing, you give me a reason for your unavailability and the Bureau of Hearings and Appeals deems the reason to be acceptable, the hearing will be postponed. If the Bureau of Hearings and Appeals deems your reason to be unacceptable and you are not available for the hearing, your appeal will be dismissed. CONTINUED ON REVERSE Please complete and sign the "REPLY TO BUREAU OF HEARINGS AND APPEALS" form below, out on the dotted line and return as soon as possible In the postage-paid reply envelope to the Bureau of Hearing and Appeals. .......................................................... •.......................................................................................... REPLY TO BUREAU OF HEARINGS AND APPEALS Check all that apply: I will be available for the hearing on March 14, 2012 ? at 10:00 a.m. with ALJ C Michael Lane M My correct telephone number I need an interpreter. Language needed: M I will NOT be available for the hearing because: r7 I wish to withdraw my appeal at this time (Only the person who filed the appeal or his/her authorized representative can withdraw the appeal). Signature Date PW 1765A I am a person with a disability and I need an accommodation to participate in the hearing The accommodation I need is: Ruth C. Aubin 210163127-001 PW 1765 - 3163 •QnnrgQAn 1 n 1 BROCHURE: A brochure is included with this notice which provides a summary of the hearing process and information regarding optional hearing methods. If you have any questions regarding the contents of this notice or the brochure, please contact my office at the telephone number in the heading of this letter. The Bureau of Hearings and Appeals complies with the Americans with Disabilities Act. We will provide reasonable accommodations upon request. Please contact my office at the address or telephone number in the heading of this letter if you wish to discuss special accommodations OR you may describe the accommodation on your "Reply to the Bureau of Hearings and Appeals". Sincerely, Timothy D. Book Site Administrator cc: Cumberland GAO Ivana Grujic WAM Please complete and sign the "REPLY TO BUREAU OF HEARINGS AND APPEALS" form below, cut on the dotted line and return as soon as possible in the postage-paid reply envelope to the Bureau of Hearing and Appeals. BUREAU OF HEARING AND APPEALS 2330 VARTAN WAY SECOND FLOOR HARRISBURG PA 17110-9946 PW 1765B PW 1766 -11/01 EXHIBIT ""E (TO COMPLAINT) SCHUTJER BOGAR Ty 309 FELLOWSHIP ROAD, SUITE 200 MT. LAUREL, NJ 08054 4 856-533-2461 ® SCHUTJERBOGAR.COM $1lfai1 : *mgfeftehug4wboVv.C= Dhvd Dial: WO 688-4+164 February 24, 2012 VIA OVERNIGHTMAIL Michael Bless 22 Summit Place Cedar Hill, TX 75104 Re: Roth Aubin - Medicaid Benefits Dear Mr. Bless: As you are aware, our firm represents Church of God Home, Inc. ("Church of God") in relation to its Medicaid eligibility and reimbursement needs. We have been asked by Church of God to assist in securing Medicaid benefits for your mother, Ms. Ruth Aubin ("Ms. Aubin.") By way of this letter, I am seeking your compliance, as the agent for Ms. Aubin, with the Medicaid regulations governing eligibility for Medicaid benefits. As you know, an application for Medicaid was filed on Ms. Aubin's behalf in August 2011 with the Cumberland County Assistance Office of the state of Pennsylvania ("CAO"). In processing your mother application, we have learned that Ms. Aubin's assets exceed the resource limit established by the state Medicaid regulations governing eligibility for Medicaid benefits. Specifically, as of September 24, 2011, Ms. Aubin had $3,299.00 in her Member's tat Bank account no. 50026 and $4,835.00 in her Member's 18t Bank account no. 413920. These resources exceed the resource limit established by the state Medicaid regulations and will result in a denial of your mother's application for Medicaid benefits unless immediate action is taken. Bless, Michael February 24, 2012 Page 2 As a result, a spend-down of Ms. Aubin's funds in accordance with the state Medicaid regulations, i.e., payment of your mother's medical expenses, is necessary in order to qualify Ms. Aubin for Medicaid benefits. It is imperative that these resources are spent down immediately to prevent the loss of benefits. Accordingly, please promptly spend-down Ms. Aubin's resources in accordance with the Medicaid eligibility guidelines to bring her within the resource-limit set forth by the state Medicaid regulations and provide proof of the same in the form of copies of checks, bank statements, withdrawal receipts, or other written confirmation showing that his resources have been spent-down. In order to expedite this process, kindly fax all copies directly to my attention at (856) 533- 2461. Again, it is crucial that this be completed as soon as possible. If I do not receive any documents or hear from you by Wednesday, March 7, 2012, I will assume you will not be cooperative and we will proceed accordingly. We appreciate your cooperation and prompt attention to this matter. Sincerely, SCHUTJER BOGAR Ivana Grujic, Esq. UPS: Tracking Information Proof of Delivery Close Window Dear Customer, This notice serves as proof of delivery for the shipment listed below. Tracking Number: 1ZY99V530195567096 Reference Number(s): CGH-038 Service: UPS Next Day Air® Shipped/Billed On: 02124/2012 Delivered On: 02127/2012 10:15 A.M. Delivered To: 22 SUMMIT PL CEDAR HILL, TX, US 75104 Left At: Other - released Thank you for giving us this opportunity to serve you. Sincerely, UPS Tracking results provided by UPS: 03105/2012 11:21 A.M. ET Print This Pape Close Window Page 1 of I https://wwwapps.ups.com/WebTrackinglprocessPOD?IineData--Mesquite%5EFS%5EUnite... 3/5/2012 EXHIBIT "F )I (TO COMPLAINT) RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 Statement Date Due Date 12/31/2011 Upon Receipt 802839 AMOUNT PAID $ RUTH C AUSIN C/o MICHAEL BLESS 22 SUMMI T PLACE CEDAR HILL, TX 75104 $0.00 $(88.19) Please make check payable to CHURCH OF GOD HOME, INC Remit To: CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. $0.00 $30,248.91 1 $30,300.99 Balance Forward $30,389.18 $30,389.18 08/17/11 - 08/17/11 Pharmacy OTC (1) $15.07 $(15.07) $30,374.11 08/17/11-08/17/11 Pharmacy Free Care (1) $57.00 $(57.00) $30,317.11 10/27111 -10/27/11 Pharmacy OTC (1) $16.12 $(16.12) $30,300.99 TOTAL BALANCE DUE: $30,300.99 ACCOUNT NUMBER FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC RUTH C AUBIN 802839 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA -TJ CHURCH OF GOD HOME, INC., G Plaintiff/Petitioner, Docket No. rim V. Y CIVIL ACTION - EQtft co f --ate RUTH AUBIN, individually and ?.`?D :]a by and through her Agent, v " MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, Defendants/Respondents. EMERGENCY PETITION FOR PRELIMINARY INJUNCTION AND NOW, comes Church of God Home, Inc. ("Church of God"), by and through its attorneys, SCHUTJER BOGAR, and files the following Emergency Petition for Preliminary injunction against Respondents Ruth Aubin ("Respondent Aubin") and Michael Bless ("Respondent Bless"), (collectively, "Respondents"), pursuant to Pa.R.C.P. § 1531, and, in support thereof, avers: 1. Contemporaneous with the filing of this Emergency Petition, Church of God is filing its Complaint against Respondents. See Complaint attached hereto as Exhibit "1." 2. The Complaint sets forth an equitable claim against Respondents relating to their breach of the Nursing Care Admissions Contract ("Agreement") that Respondents entered into in conjunction with the admission of Respondent Aubin to Church of God's skilled nursing facility. See Agreement attached to Complaint as Exhibit "B." 3. Specifically, the Complaint alleges that Respondents breached the Agreement by failing to ensure that Respondent Aubin's assets were within the eligibility requirements for ORIGINAL' Medical Assistance benefits, and Respondents continue to breach the promise owed to Church of God by not providing to the Cumberland County Assistance Office ("CAO") verification demonstrating that Respondent Aubin's excess resources have been reduced to the necessary level to qualify her for Medical Assistance. See Exhibits "C," "D," and "B" to Complaint. 4. Moreover, in the Agreement, Respondents assigned to Church of God Respondent Aubin's right to Medical Assistance benefits (hereinafter "the Assignment Clause"). See Exhibit "B" to Complaint. 5. Accordingly, Church of God now stands in the shoes of the assignor and has assumed Respondent Aubin's rights with respect to her Medical Assistance benefits. See Horbal v. Moxham Nat'l Bank, 697 A.2d 577 (Pa. 1997) ("[A]ssignee stands in the shoes of the assignor and assumes the rights of the assignor.") 6. However, Respondents' failure to provide the verification documentation that the CAO requires to process and approve Respondent Aubin's application for Medical Assistance benefits is in breach of the Agreement and interferes with Church of God's rights to the Medical Assistance benefits that have been contractually assigned to it. See Exhibit "B" to Complaint. 7. The CAO denied Respondent Aubin's application for Medical Assistance benefits because Respondent Aubin was over the applicable Medicaid resource limit, and an appeal hearing on this denial has been scheduled for March 14, 2012. See Exhibits "C" and "D" to Complaint. 8. Respondents' continued failure to comply with the terms of the Agreement and provide the verification information required by the CAO by March 14, 2012 will result in failure of the appeal. 2 9. The very nature of the breach of this contractual obligation, i.e., the failure of Respondents to secure Medical Assistance benefits from March 14, 2011 through October 28, 2011 by failing to appropriately spend down Respondent Ruth Aubin's countable resources on qualified medical expenses and provide to the CAO proof of same by the March 14, 2012 hearing has caused immediate and irreparable harm to Church of God. Due to the above breach, Church of God cannot realize the benefit of the bargain promised to it under the Assignment and the Agreement, including specifically, Church of God's right to Respondent Aubin's Medical Assistance benefits, and by extension, its right to be compensated for the skilled nursing services it has provided to Respondent Aubin. 10. Respondents have been made aware of the necessity of spending down Respondent Aubin's resources in order to qualify her for Medical Assistance benefits, and Respondent Bless has repeatedly made assurances that the resources would be spent down and proof of same would be provided to Church of God. See Exhibit "E" to Complaint. 11. To date, Respondent Bless has not provided said proof. Thus, although Church of God has preserved Respondent Aubin's right to pursue Medical Assistance benefits through filing a timely appeal of the denial based on Respondent Aubin's countable resources being in excess of the applicable Medicaid limits. However, if Respondents continue to refuse to cooperate in the Medical Assistance eligibility determination process by failing to appropriately spend down Respondent Aubin's countable resources on allowable medical expenses, the appeal will fail and the current balance of Thirty Thousand, Three Hundred and 99/100 ($30,300.99) Dollars will go unpaid. 12. The requested preliminary injunction would restore the parties to the status quo as it existed immediately prior to Respondents' breach of the Agreement. 3 13. Greater injury would result from the denial of the requested injunction than from the granting of the same, because, absent the injunction ordering that Respondents' appropriately spend down Respondent Aubin's countable resources on allowable medical resources and without Respondents' cooperation with the Medical Assistance process, Church of God's ownership rights in the Medical Assistance benefits that have been assigned to it, and its ability to receive compensation for the skilled nursing services it has provided, will be forever lost. 14. Church of God's right to relief is clear. See Exhibit "B" to Complaint. 15. Church of God lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Respondent Aubin has been financially unable to fully compensate Church of God for the services that it has rendered. 16. A bond in the amount of $100.00 should be adequate in the event that it is later determined that the issuance of the instant Emergency Petition was in error. WHEREFORE, Church of God respectfully requests that this Court enter an Order requiring the specific performance of Respondents' contractual obligations under the Agreement, specifically requiring Respondents immediate cooperation in the Medical Assistance benefits process, including, but not limited to: (1) immediately executing the Authorization Statement; (2) requiring that Respondents spend down any excess assets of Respondent Aubin in accordance with applicable Medical Assistance regulations and provide proof of same to Church of God by the March 14, 2012 hearing; (3) ordering Respondents to timely and completely accommodate any other requests made by the CAO within five (5) days of written notice by Church of God; and (4) ordering Respondents to recover and return all resources belonging to Respondent Aubin which were transferred at less than fair market value or were not utilized solely for Respondent Aubin's best interests. 4 Dated: -y Respectfully submitted, SCHUT R OG By: Kirk Sohonage, Esq. PA Attorney I.D. No. 77851 1426 N. 3`d Street, Suite 200 Harrisburg, PA 17102 Phone: (717) 909-8160 Fax: (717) 909-5925 Ivana Grujic, Esq. PA Attorney I.D. No. 311922 309 Fellowship Road, Suite 200 Mount Laurel, NJ 08054 Phone: (856) 533-2464 Fax: (856) 533-2461 Attorneys for Church of God EXHIBIT "1" Supreme G Cour CU A nnsy C o leas ?t vania County For Prothonotary Use Only: Docket No: The information collected on this form is used solely for court administration purposes. This form does not ,_ _ r_,_-__ _•_a !. l ,14;,? „r nfAor »nnorc nc rpnuired by law or rules of court. Nature of the Case: Place an "X" to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim,:. check the one that you consider most important. TORT (do not include Mass Tort) ® Intentional E3 Malicious Prosecution l3 Motor Vehicle Nuisance Premises Liability S l3 Product Liability (does not include E mass tort) l3 Slander/Libel/ Defamation C, , 0 Other: T L 0 MASS TORT ® Asbestos N Tobacco B` CONTRACT (do not include Judgments) ® Buyer Plaintiff Debt Collection: Credit Card ® Debt Collection: Other ® Employment Dispute: Discrimination 13Employment Dispute: Other ®x Other: Specific Performance/ Breach o Contract suPPterrtertt yr IGyeuL-c i,Xc facorss Commencement of Action: El Complaint U Writ of Summons l Petition 13 Transfer from Another Jurisdiction Declaration of Taking Lead Plaintiff s Name: Lead Defendant's Name: CHURCH OF GOD HOME, INC. RUTH AUBIN Dollar Amount Requested: within arbitration limits Are money damages requested? [3 Yes l? No (check one) NSA Qoutside arbitration limits Is this a Class Action Suit? 13 Yes I@ No Is this an MDJAppeal? [3 Yes [M No Name of Plaintiff/Appellant's Attorney: SCHUTJER BOGAR - KIRK S. SOHONAGE l3 Check here if you have no attorney (are a Self-Represented [Pro Sel Litigant) REAL PROPERTY l3 Ejectment 0 Eminent Domain/Condemnation 0 Ground Rent 0 Landlord/Tenant Dispute l3 Mortgage Foreclosure: Residential l3 Mortgage Foreclosure: Commercial Partition Quiet Title l3 Other: CIVIL APPEALS Administrative Agencies l3 Board of Assessment ® Board of Elections Dept. of Transportation Statutory Appeal; Other ® Zoning Board El Other: MISCELLANEOUS Q Common Law/Statutory Arbitration Declaratory Judgment Mandamus Non-Domestic Relations Restraining Order 13 Quo Warranto l3 Replevin ll Other: Updated 1/1/2011 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, Docket No. V. CIVIL ACTION - EQUITY RUTH AUBIN, individually and by and through her Agent, MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, Defendants. NOTICE TO DEFEND Pursuant to PA RCP No. 1018.1 YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after their complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the Church of God. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THEIR OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THEIR OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 Phone: (717) 249-3166 or (800) 990-9108 EN LA CORTE DE ALEGATOS COMUN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, Docket No. V. CIVIL ACTION - EQUITY RUTH AUBIN, individually and by and through her Agent, MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, Defendants. AVISO PARA DEFENDER Conforme a PA RCP Num. 1018.1 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falls de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 Phone: (717) 249-3166 or (800) 990-9108 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff, Docket No. V. CIVIL ACTION - EQUITY RUTH AUBIN, individually and by and through her Agent, MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, Defendants. COMPLAINT AND NOW, comes Church of God Home, Inc. ("Church of God"), by and through its attorneys, SCHUTJER BOGAR, and files the within Complaint against Defendants Ruth Aubin ("Defendant Aubin") and Michael Bless ("Defendant Bless"), (collectively, "Defendants"), and in support thereof, provides as follows: 1. Church of God is a corporation created and existing under the laws of the Commonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 2. Defendant Aubin is an adult individual who currently resides at 4837 East Trindle Road, Mechanicsburg, Pennsylvania 17050. Defendant Aubin was a prior resident of Church of God's skilled nursing facility located at 801 North Hanover Street, Carlisle, Pennsylvania 17013 from March 14, 2011 to October 28, 2011. 3. Defendant Bless is an adult individual who currently resides at 22 Summit Place, Cedar Hill, Texas 75104. Defendant Bless is the son of and Agent for Defendant Aubin. See Power of Attorney attached hereto as Exhibit "A" and incorporated by reference. 4. On or about March 14, 2011, Defendant Aubin was admitted to Church of God's skilled nursing facility. 5. At the time of Defendant Aubin's admission to Church of God's skilled nursing facility, and at all times relevant hereto, Defendant Bless was operating as Defendant Aubin's Responsible Party and Agent under a Power of Attorney. 6. On or about March 14, 2011, Church of God and Defendants entered into a written Nursing Care Admissions Contract ("Agreement"), pursuant to which Church of God agreed to provide Defendant Aubin with skilled nursing services in exchange for, inter alia, Defendants' promise to pay a specific monetary fee from Defendant Aubin's resources and promise to "complete the application and enrollment process for Medical Assistance benefits... in a timely manner." See Agreement pg. 9. A true and correct copy of the Agreement is attached hereto as Exhibit "B" and incorporated by reference. 7. The Agreement also assigned to Church of -God Defendant Aubin's right to apply for and obtain Medical Assistance benefits ("Assignment"). 8. Additionally, in furtherance of that Assignment, Defendants "irrevocably authorize[d] the Facility to make claims and to take such other actions as maybe necessary for the Facility's receipt" of those benefits in order to "satisfy charges under [the] Agreement." See Agreement pg. 51. 9. After Defendant Aubin was admitted to Church of God's skilled nursing facility, she allegedly became insolvent and her bills for skilled nursing care went unpaid. 2 10. As a result, an application for Medical Assistance benefits was filed on Defendant Aubin's behalf with the Cumberland County Assistance office ("CAO") on or about July 2011. 11. On November 29, 2011, the CAO issued a denial of Defendant Aubin's application for Medical Assistance benefits. See PA-162 attached hereto as Exhibit "C" and incorporated by reference. 12. Specifically, the CAO denied Defendant Aubin's application because Defendant Aubin was over the applicable Medicaid resource limit, and thus, was ineligible for assistance. See Exhibit "C." 13. After receiving the denial notice of benefits, Church of God appealed the decision on behalf of Defendant Aubin on December 19, 2011. This appeal was supplemented by Church of God's attorneys, SCHUDJER BOGAR, on December 22, 2011. 14. A hearing on this appeal has been scheduled for March 14, 2012. See Notice of Hearing attached hereto as Exhibit "D." 15. Defendants have been made aware of the necessity of spending down Defendant Aubin's excess resources in order to qualify her for Medical Assistance benefits, and Defendant Bless has repeatedly made assurances that the resources would be spent down and proof of same would be provided to Church of God. See February 24, 2012 correspondence attached hereto as Exhibit "E." 16. To date, however, Defendants have not provided said proof to either the CAO or Church of God. 17. Thus, although Church of God has preserved Defendant Aubin's right to pursue Medical Assistance benefits through the filing of a timely appeal, if Defendants continue to refuse to cooperate in the Medical Assistance eligibility determination process by failing to 3 appropriately spend down Defendant Aubin's countable resources on allowable medical expenses by the March 14, 2012 hearing date, the appeal will fail. Therefore, Church of God will be precluded from receiving the Medical Assistance benefits that have been contractually assigned to it for the skilled nursing services provided to Defendant Aubin from March 14, 2011 through October 28, 2011. 18. To date, an outstanding balance of Thirty Thousand, Three Hundred and 99/100 ($30,300.99) Dollars is owed to Church of God for the skilled nursing services it provided to Defendant Aubin under the Agreement. See Invoice attached hereto as Exhibit "F" and incorporated by reference. COUNTI BREACH OF CONTRACT/SPECIFIC PERFORMANCE CHURCH OF GOD v. DEFENDANTS 19. The allegations contained in Paragraphs 1 through 18 are incorporated by reference as though restated in full. 20. Pursuant to the Agreement entered into with Church of God, Defendants agreed to cooperate fully with the Medical Assistance determination process and to pay Church of God from the resources and assets belonging to Defendant Aubin. 21. Church of God provided skilled nursing services to Defendant Aubin pursuant to the terms of the Agreement. 22. However, in breach of the Agreement, Defendants have not cooperated fully with Church of God to secure Medical Assistance payments for Defendant Aubin's care; in fact, Defendant Aubin was deemed ineligible for Medical Assistance benefits towards the cost of long term care precisely because Defendants refused to appropriately spend down Defendant Aubin's countable assets on allowable medical expenses so that she could qualify for Medical Assistance 4 benefits. 23. If Defendants fail to appropriately spend down Defendant Aubin's countable resources on allowable medical expenses by the March 14, 2012 hearing, the appeal will fail and Defendant Aubin will not be eligible for Medical Assistance benefits. 24. Therefore, if Defendants fail to appropriately spend down Defendant Aubin's countable resources on allowable medical expenses by the March 14, 2012 hearing, Church of God will remain unpaid for the skilled nursing services it provided to Defendant Aubin from March 14, 2011 through October 28, 2011. Therefore, Church of God is precluded from receiving the benefit Defendants assigned to it. 25. Upon information and belief, at all times material hereto, Defendant Aubin has been financially unable to fully compensate Church of God for the services that it has rendered to her in accordance with the terms and conditions of the Agreement. 26. Defendants' breach of the Agreement with Church of God has irreparably harmed and continues to cause Church of God irreparable harm. 27. Only a decree of specific performance will adequately protect the interests of Church of God and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Church of God respectfully requests that this Court enter an Order requiring the specific performance of Defendants' contractual obligations under the Agreement, specifically requiring Defendants immediate cooperation in the Medical Assistance benefits process, including, but not limited to: (1) immediately executing the Authorization Statement; (2) requiring that Defendants spend down any excess assets of Defendant Aubin in accordance with applicable Medical Assistance regulations and provide proof of same to Church of God by the 5 March 14, 2012 hearing; (3) ordering Defendants to timely and completely accommodate any other requests made by the CAO within five (5) days of written notice by Church of God; and (4) ordering Defendants to recover and return all resources belonging to Defendant Aubin which were transferred at less than fair market value or were not utilized solely for Defendant Aubin's best interests. Dated: W (-Z. By: Respectfully submitted, SCHUTJER BOGAR 11/11V Kirk So o ag , Esq. PA Attorney I.D. No. 77851 1426 N. 3rd Street, Suite 200 Harrisburg, PA 17102 Phone: (717) 909-8160 Fax: (717) 909-5925 Ivana Grujic, Esq. PA Attorney I.D. No. 311922 309 Fellowship Road, Suite 200 Mount Laurel, NJ 08054 Phone: (856) 533-2464 Fax: (856) 533-2461 Attorneys for Church of God 6 VERIFICATION The undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C.S.A. § 4904, relating to unsworn falsification to authorities. ?7) Dated: L. Karen Stephenson, Rep sentative of Church of God H?, Inc. ?? Q?,? EXHIBIT"A" (TO COMPLAINT) ? i I f I ADVANCE HEALTH CARE DECLARATION (LIVING WILL) AND HEALTH CARE POWER OF ATTORNEY OF RUTH AUBIN 1, RUTH AWBIN, of 130 Tower Circle, Carlisle, Cumberland County, Pennsylvania, being of sound mind, willfully and voluntarily make this declaration to be followed if I become incompetent or unable to express myself. This declaration reflects my commitment to refuse life-sustaining treatment if I have a terminal or end-stage medical condition or am in a state of permanent unconsciousness, including a persistent vegetative state or irreversible coma. If I am in such condition or state, I direct my attending physician(s) to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, and that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that might result from the withholding or withdrawal of life-sustaining treatment, 1 l even if such measures may hasten the moment of my death. Furthermore, if I am ever in such condition or state, i leave the following directions concerning my medical treatment: 1do Ido not SKIS, L JOWER2 & ( ] ( } want cardiac resuscitation. UMS" "6 W= Nigh Sven [ } X want mechanical respiration. CuUt. PA [ }) want tube feeding or any other artificial or invasive form of nutrition. l } Ido Ido not ] [ : J want hydration (water) as may be necessary for my comfort. want blood or blood products. ( ] [ want any form of surgery or invasive diagnostic tests. want kidney dialysis. want antibiotics or medication other than pain-relieving medication. ( ] ( want chemotherapy. I realize that if I do not specify my preference regarding any of the forms of treatment listed above, I may receive that form of treatment. I designate the following person as my health care agent to make medical treatment decisions for me if I should become incompetent or unable to express myself, whether or not t have a terminal or end-stage medical condition or am in a state of permanent unconsciousness. Name and address of health care agents: Name: David G. Au in Address. flU )qovZ/ Toledo, 10 ?3 Home Phone: 7_ and Name: Michael R. Bless Address: SAUDIS, _OVV R Ss LUNDS" 5 wear HO street Caviare. PA Dallas and Commerce, Texas Horne Phone: fly 'p_ .,'-5 POA My health care agent or substitute agents appointed hereunder shall have those of the following powers marked "Yes," subject to my directions in this Combined Living Will and Health Care Power of Attorney: 2 Yes No (,j ( ) 1. To authorize my admission to, or discharge from, a medical, nursing, residential, or similar facility and to enter into agreements for my care. 2. To access, and to authorize others to access, any and all medical information and records of mine and/or about me; as my Personal Representative under the Health Insurance Portability and Accountability Act of 1995 (HIPAA), to receive my protected health information and to authorize the disclosure and use of my protected health information as provided in 45 CFR Part 164. X [ ) 3. To employ and discharge medical and related personnel. j [ J 4. To authorize medication, surgical procedures, and/or other medical care for curative purposes, for treatment of specific symptoms, and to relieve pain. If I am suffering under a terminal condition from which 1 cannot recover, in the opinion of my attending physician, l specifically recognize and accept that an authorized meditation and procedure to relieve pain or a specific symptom may accelerate my death. j ] 5. To complete insurance, admission, and other health-related forms, applications, certifications, and documentation. j ] 6. To grant releases to health care professionals or institutions. 1.4 j 1 7. To authorize the donation of my anatomical parts. 8. Any power herein to authorize an action shall also be deemed to be a power to deny or withhold authorization of specific acts. SA.IDIS, LOWER & LINDSAY b West High Street Culisk, PA 9. Subjecf- to any substitutes named herein, to appoint successor or substitute health care agents hereunder. I hereby approve, ratify, and confirm any action taken by my said health care agent and substitute agent(s) appointed hereunder, until this Declaration is duly revoked under my hand and seal. This Combined Living Will and Health Care Power of Attorney and grant 3 of powers thereunder to my health care agent and substitute agent(s) shall not be affected by my disability, incapacity, incompetency, or by uncertainty as to whether I am dead or alive. ...., .•''?`? I have signed this Declaration on this 15` day of April, 2008. a Declarant's signature: : - f z- Ruth Aubin Declarant's address: 130 Tower Circle Carlisle, PA 17013 The Declarant knowingly and voluntarily signed this writing by signature or mark in our presence. : f Witness's signatumg-? Witness's address: 2,6 West High Street Carlisle, PA 17013 Witness's signature: lr Witness's address: 26 est High Street Carlisle, PA A7013 SAMIS LJMS" Wes? Haigh Street Carl4k, PA 4 . X. 13. 20 11 11:I2AM NO. 1636 P. 2/6 GENERAL POWEft.O.F. ATTORNEY OTICE THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE (YOUR 'AGENT") BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL. BY YOU. THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE GRANTED POWERS; BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY, YOUR AGENT MAY EXERCISE THE POWERS GIVEN' HERE THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY. YOUR AGENT MUST DEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURT CAN. 'T'AKE AWAY TIME POWER OF YOUR AGENT IF IT FINDS YOUR AGENT IS NOT ACTING PROPERLY. THE POWERS AND DUTIES OF AN AGENT UNDER' A POWER OF ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH ,56. IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. MY ATTORNEYS, SAIDIS, FLOWER & LINDSAY, HAVE EXPLAINED THIS NOTICE AND THE POWER OF ATTORNEY TO ME, I HAVE HAD THE OPPORTUNITY TO ASK QUESTIONS AND I UNDERSTAND THE CONTENTS OF THESE DOCUMENTS. Date Ruth Aub , PrLnCIgal MAR. 13. 20 11 11:12AM POWER OF ATTORNEY NO, 7636 P. 3/6 1, Ruth Aubin of North Middleton Township, Cumberland County, Pennsylvania (`P'rino/pan, hereby appoint Michael R. Bless of 22 Summit Place, Cedar Hill, Texas (hereinafter referred to as Iny Agent7 my Agent. My Agent shall have full power of substitution, for me and in my name, to transact all business and to manage all my property and affalrsa as I might do If personally present. 1. Speclficadon of Powers In addition to the above general powers, my Agent and ray Successor Agent shall have the toibwing speft powers (1) To make limited 9ft of my property, in equal amounts to my issue, including my Agent (2) To create a trust for my benefit. (3) To make addlions to an existing trust for my benefit. (4) To Bairn an eleotive share of the estate of my dvAosed spouse. (5) To dWalm any Intared in property. (6) To renounce fiduciary positions. (7) To withdraw and receive the income or corpus of a trust. (8) To autho* my admission to a medical, nursing, residential or similar f ellity and to enter Into agreements for my care. (9) To authorize medical and surgical prooedures. (10) To engage In real property transactions. (11) To engage in tangible personal property transac dons. (12) To engage in stock, bond and other securities transactions. (13) To engage in banking and financial transactions. (14) To borrow money. 2 MAR. 18.2011 11.12AM (15) To enter safe deposit boxes. (16) To engage In Insurance transactions. (17) To engage in retlrement plan transactions. (18) To handle Interest in estates and masts. (19) To pursue Balms and litigation. (20) To nwelve government benefits. (21) To pursue taut matters. (22) To make an anatomical gift of all or part of my body, NO. 7636 P. 4/6 II. [hoai= am. For the purposes of this Power, a letter from a dulyNbensed physlstan sating that after a m1hation an Agent named herein is merdally or pby*mgy incapacitated, as such that he or she would' be unable to act as my Agent, shall be conclusive proof of such Agef°s IncepwN, Iii. Durable EMM gf, -ft r,?y. This is a durable power of attorney and it shall not be affected by my subsequent disable or Incapeft All acts done by my Agent pursuant to this per sail have the same effect and shall Inoue to my ben+atit and bind me and my sugars in Interest as iii were corm and not disabled. IV. AgifficaUon. I hereby ratify and confirm all that my Agent or my Sucoessor Agents shmtl lawfully do or cause to be done by virtue hered V. +Ca efftiaa Aw. This power of stlomey shall be 00r cted by and Interpreted in accordance mdth the laws of the Common wealth of Pennsylvania. IN WITNESS WHEREOF, I have hereunto set my hand and seal on this, the 250 day of May, 20113. WITNESS: d-Q? OA, -A4 to k?4? -1?? C. a4"f- Rath Aubfh, Principal 3 !YiXR.1 ?, ? 0 i 1 11:13AM NO, 7636 P. 5/6 COMMONWEALTH OF PENNSYLVANIA ) . ss. COUNTY OF CUMBERLAND y On this, the 25" day of May, 2010, before me, a notary public, the undersigned officer, personally appeared Ruth Aubin known to me (or saWac3ttorily proven) to be ft person whose name Is subscribed to the within Power of Atfiomey, and acknowledged that she executed the same for the purpose therein contained. IN WITNESS WHEREOF, I have hereunto set my hand and official seal. Notary Public 1110 c cM tine 7 ?Oit 4 t, 2911 11:1JAM NQ.7636 P, b/b ?r ACKNOWLEGMENT BY AGENT AND SUCCESSOR AGENT 1. Michael R. Riess, have read the attached Power of Attorney and am the person tdentlfted as the Agent for the principal. I hereby acknawledge 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 keep a full and accurate record of all actlons, receipts and disbursements on behalf of the :principal. DA 7 5 EXHIBIT'*'*B" (TO COMPLAINT) I CHURCH OF GOD HOME "Committed to Curing" Nursing Care Admissions Contract Information Church of God Home, Inc. 801 N. Hanover Street - Carlisle, PA 17013 P: (717) 249-5322 • F: (717) 249-8622 I Revised 01/2 011 42b? CHURCH OF GOD HOME "Committed to Curing" Dear Friend: Admission into a health care facility is a learning experience, both for the new resident and their family. We at the Church of God Horne try to make the admission process as positive, pleasant and easy as possible. Because of the number of documents that must be explained and signed upon admission, many facilities look at this as being 'overwhelming". However, both State and Federal regulations require such forms for permanent records. As we welcome the new resident, a hand is extended in friendship... an arm is offered for support ... a cheerful pat of enoouragement is given... these are a few of the special touches that the Church of God Home has been offering since its doors first opened in 1948. For more then sixty years a Christian spirit has been the guiding philosophy of our Home. That's the reason our care goes far beyond just meeting the physical needs of our residents. We believe in the dignity and self-worth of each individual, and every aspect of our care reflects that belief. Our mission is to minister to the physical, spiritual, and emotional need of each resident in order to help him or her lead a more meaningful life. In sharing these values and standards of the Church of God Home, we hope that our experience will benefit others so that, together, we will continue to find better ways to serve the needs of elderly people in our society. , 9/ /11 W--e Carson G. Ritchie, CPA, NHA President/CEO 2 Table of Contents 1. Welcome Letter ..........................................................................................................................2 2. Statement of Vision and Mission .......................................................................................... .......4 3. Ambulance ........................................................................................................................... .......4 4. Chart of Costs ...................................................................................................................... ... 5-7 5. Dietary Services ..................................................................................................................... 7-8 6. DVD "A Time of Transition" .........................................................................................................8 7. Guest Room ........................................................................................................................ .......8 8. America's Best Medical ..............................................................................................................9 9. Medicaid (Medical Assistance) ............................................................................................. 9-10 10. Medicaid (Medical Assistance) Residents .................................................................. .. ....11 11. Medicaid (Medical Assistance) Residents Cheddist ........................................................... 12-13 12. Medicare ............................................................................................................................. 14-15 13. Mobile X-Ray Imaging, Inc.... .............................................................................................. ...... 16 14. Psychiatrist ...............................................................................................................................16 15. Smoke Free Environment .........................................................................................................17 16. Specialized Services ........................................................................................................... ......17 17. Transportation .................................................................................................................... ......17 18. Understanding Restraint Use .............................................................................................. ......18 19. Advance Directive Policy .................................................................................................... ......19 20. Complaint Procedure .......................................................................................................... ......20 21. Delegation of Responsibility Form ...................................................................................... ......21 22. Legal Rights Compliance ......................... 23. Non-Discrimination Statement ................................................................................... .... ......23 24. Personal Cash Accounts / Depleted Funds ........................................................................ 24-25 25. Personal Laundry Service ......................................................................................... ...... ......26 26. Pharmacy Services ............................................................................................................. 27-34 27. Podiatry Services ................................................................................................................ ......35 28. Privacy Act Statement- Healthcare Records ..................................................................... 36-37 29. Private Room Policy I Nursing ............................................................................................ ......38 30. Therapy ............................................................................................................................. ......39 31. Vaccinations ....................................................................................................................... 40-45 32. Valuables ............................................................................................................................ ......46 33. Admission and Care Agreement ......................................................................................... 47-55 a. Security Deposit ........................................................................................................... ......47 b. Late Charge ................................................................................................................. ......48 c. Readmission - Bed Hold Policy .................................................................................. ......49 34. Resident I Family Guide to Inquiries and Information ......................................................... 53-54 35. "Welcome" (Telephone/Extension) ..................................................................................... ......55 36. Checklist ............................................................................................................................. ......56 3 STATEMENT OF VISION AND MISSION Vision To provide an aging services' continuum of care that reflects the perfect love of Christ, exceeding the expectations of those we serve. Mission Church of God Home, a Continuing Care Retirement Community, is a Christian Ministry committed to caring for the body, mind and spirit of older persons. Admissions Policy It is the policy of the Church of God Home, a unit of the Eastern Regional Conference of The Churches of God, to admit and treat all persons without regard to race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. Only those applicants whose medical nursing care, psychological and behavioral needs can be adequately met by the staff, will be admitted or kept in this facility. In addition, all residents must meet the financial criteria of private pay, Medicaid or SSI payer source. The Board of Trustees is committed to providing housing, services and needed responsible care for older persons with priority to those who are members of, or affiliated with, the Eastern Regional Conference of The Churches of God. The same requirements for admission are applied to all, and residents are assigned within the facility without regard to race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. There is no distinction in eligibility for, or in any manner of, providing any resident service that is provided by or through the facility. All areas of the healthcare center are available to all persons and visitors regardless of their race, color, national origin, age, ancestry, sex, handicap, disability or religious creed. All persons applying for admission, or who are recommending individuals to the Church of God Home, are advised to do so without regard to the person's race, color, national origin, age, ancestry, sex, handicap, disability, or religious creed. Ambulance Ambulance enrollment is recommended but is not handled by the facility. If you desire enrollment, please contact them independently. 4 Chart of Costs Nursing Care Room Rates Faith Wing and Love Wing Semi-Private $249.00 per day-?' Private $302.00 per day Personal Care Room Rates Effective January 1, 2011 Hope Wing and Peace Wing ;Semi-Private $111.00 per day (Rm401-411) Private $119.00 per day (Rm301) $130.00 per day (Rm303-313) $139.00 per day (Rm400) Creekside Apartments Studio One Bedroom One Bedroom, Creek view One person $153.00 per day $173.00 per day $178.00 per day Two persons $257.00 per day $284.00 per day $331.00 per day Note: There will be a security deposit charged based on a 31-day month at the per diem rate for room/level of care. In the event of a Level of Care change to a higher level the resident/responsible party will be billed the difference between the security deposits. There are no additional charges while receiving benefits under the Medicare program while in nursing care (except telephone, hair care, personal laundry, transportation, bed hold, bed reserve and name labels). Independent Living Rates LeTort Manor Apartments Apartment Monthly Maintenance Fee One Person Two Persons A $942 $1,264 3 $868 $1,170 C $868 $1,170 D $853 $1,160 E $853 $1,160 Apartment Type 40% Refundable Rate Non-Refundable Apartment "A" $109,000 $83,000 Apartment "B" $96.100 $73,000 Apartment "C" $96,100 $73,000 Apartment "D" $81,000 $63,000 Apartment "E" $81,000 $63,000 Independent Livina Rates - Rental Rates LeTod Manor Apartments A ap rtment Monthly Rental One Person Two Persons A $2,000 $2,315 3 $1,800 $2,095 C $1,800 $2,095 D $1,600 $1,895 P $1,600 $1,895 Note: LeTort Residents who choose the monthly rental option will be charged a security deposit based on one month rental fee. 5 Chart of Costs (continued) Independent Living Rates Creekside Apartments Apartment Monthly Rental One person Two Persons Studio $1,318 $1,803 One Bedroom $1,667 $2,313 Note: There will be a Security Deposit charged for Creekside Independent Living Residents based on the monthly rate. Ancillary Services Bed Hold (during hospitalization or LOA) Per Diem rate Cable Television (Nursing and Personal Care) Cable Television (Independent Living) Cable Internet Cable Modem Clothing Name Labels Guest Room (maximum stay of 5 nights) Incontinence Supplies Liners Briefs / Pull-ups Miscellaneous supplies Keys Laundry Service (personal clothing) Medication Assistance Charge (Independent Living) Medications, Medical and adaptive equipment, Alarm pads, special requests, etc. Nutritional Supplies Oxygen Concentrator Usage Portable Oxygen Usage CPAP, and Supplies Photocopies (copies of records) Private Telephone Purchase Telephone Set Monthly Line Fee Therapy (physical, occupational, speech) Transportation Services Included $22.00/month $20.00/month $62.00 one time fee Cost 1 person - $28.00/night 2 persons - $33.00/night 25% above cost 251/6 above cost 25% above cost $5.00 $33.75/month $15.00/month At own expense unless covered by your insurance or covered by medical assistance benefits 25°x6 above cost $3.00/day, unless covered under Medicare $12.00/cylinder, unless covered under Medicare Actual cost $1.28/pg(1-20) $0.95/pg(21-60) $0.32/pg(61+) At own expense $30.60/month Actual cost unless covered under Medicare or co-payment by secondary insurance 0-10 Miles (round trip) .......................$22.00 11-50 Miles (round trip) .................. $44.00 51-76 Miles (round trip) .................. $75.00 Escorts ....................................... $10.00/hour 6 Chart of Costs (continued) Hair Care Wash & Set Wash, Set, & Color Rinse Wash & Blow Dry Wash, Blow Dry, & Color Rinse Wash & Cut Cut, Wash, & Set Cut, Wash, Set, & Rinse Cut, Wash, & Blow Dry Cut, Wash, Blow Dry, & Rinse Wash, no blow dry Oil Treatment, Shampoo, & Set Color Rinse Frost I Hi-Light Frost 1 Hi-light & Cut Dietary Services $13.00 Men's Cut $11.50 $14.20 Men's Cut & Wash $20.00 $14.00 Men's Cut & Mustache Trim $13.00 $15.20 Mustache Trim $1.50 $21.00 Women's Cut $12.50 $25.50 Tint $30.00 $26.70 Tint & Cut $42.50 $26.50 Permanents $54.05 $27.70 Permanents & Color Rinse $55.25 $8.50 Permanents; in bed $60.00 $24.50 Men / Women Wash; in bed $16.10 $1.20 Men / Women Cut & Wash; in bed $28.35 $48.00 Wash, Style, & Blow Dry; in bed $29.40 $60.50 Re-comb $8.45 Re-comb & Curling Iron $11.75 The Dietary Department offers three (3) well-balanced nutritious meals daily as well as an alternate menu for personal preference. A PM snack is available upon request at no extra charge. The department employs two Certified Dietary Managers and a Consultant Registered Dietician to provide special diets and dietary consults with residents and families. Our five-week menu cycle offers a variety of homemade items and incorporates fresh fruits and vegetables when in season. Menus are posted in several locations throughout the Home. Our large meal of the day is served mid-day and called Dinner. Our evening meal is called Supper. General Guest Meal Policy Limit four (4) guests per resident (as space permits) for all meals except holidays. Reservations must be made 48 hours in advance for general guest meals. If reservations are not made 48 hours in advance, an alternate guest meal may be served at the discretion of the Dietary Department. Holiday Guest Meal Policy On the holidays of Easter, Mother's Day, Thanksgiving, and Christmas there is a limit of two (2) guests per resident. Due to the volume of guests that may wish to dine on these holidays, the Church of God Home will accommodate the first twenty-five (25) guests to register. Since it is impossible to provide this notice to all family ' members, please share this information with your extended family. Thank you for your understanding and cooperation. Families are encouraged to participate in special meat events throughout the year, such as our Parents Day and Holiday Buffet. `.t 7 _ -? Extra Dietary Services (arrangements for these provisions should be made through your Social Worker) *`%ou will receive a separate bill from our Business Office for these services. SIZE CAKES: SEKYES qua i wt i RJR 9" Round - 2 layers 16 $22.00 % Sheet -10"x14" 16 $15.00 ? % Sheet -12"x 17" 30 $20.00 Full 60 $30.00 ICE CREAM: Hand dipped - dishes $1.00 Hand dipped - 3 al, container $17.50 Dixie Cups - (24) 4oz. containers Vanilla / Chocolate $10.00 Gt>ST MEALS: Breakfast $5.00 Dinner $7.65 Supper $6.30 Sunda and Holiday $7.65 MISCELLANEOUS: Potatoes Chips - 3 lbs. $9.75 Pretzels - 3 lb. $7.55 Punch -1 al. $4.00 Lemonade -1 al. $4.00 Iced Tea -1 al. $4.00 Cookies -1 doz. An Kind $3.50 NOTE: All of the above items include paper-serving products and must be ordered 1 week in advance. Special Orders will be priced by Dietary Department DVD "A Time of Transition" I acknowledge that I have viewed the DVD entitled "A Time of Transition" and have been provided the opportunity to ask questions. I further acknowledge that Guide One Insurance, the Home's insurance company, recommends a viewing of this DVD. ials) r Guest Room There is a cost per night with a maximum stay of five nights. A second person in the room is an additional charge per night. No young children please. Your friend or relative will be billed for their stay. Reservation can be made through the Residential Housing Administrator (717) 249-5322 extension 3085. AMERICA'S BEST MEDICAL 2100 Gettysburg Road - Camp Hill, PA 17011 Phone 1-800-383-5303, Fax 1-800-814-9405 America's Best Medical provides Church of God Home residents with 24-hour Oxygen Service and Respiratory Supplies. They are accredited by the Community Health Accreditation Program providing weekly service to re- stock oxygen supplies, change disposable medical respiratory goods, and label and date concentrator supplies for State compliancy. Them Mission is dedicated to improving our resident`s functional abilities and overall quality of life while providing high-quality products and services that meet the highest safety standards and levels of clinical proficiency. Their commitment to service and excellence ensures the premium quality of care expected by our residents and our Home. America's Best Medical Equipment Company bills the Church of God Home directly for services and supplies. Church of God Home then bills the individual residents. For residents covered under Medicare 'Part A" or Medicaid, oxygen is included in the daily rate. Services to Personal Care Residents will be billed by America's Best directly to Medicare "Part B." MEDICAID (MEDICAL ASSISTANCE) Medicaid provides Medical Assistance to low-income persons aged 65 or over, blind, disabled, or members of families with dependent children. The Federal and State Governments jointly finance this program and it is administered by the state. Within broad general Federal Regulations, each state decides eligibility, types and range of services, payment level of servicCandnistrative and operating procedures. Medicaid's major distinction from Medicarfinanaa e. Medicare is a type of healthcare insurance. When resident resources are 5,000.00, th acility Business Office should be notified immediately. The following instructions w1. Residen0esponsible party will be responsible for a burial reserve set up at a bank or funeral home with amount equalizing enough for burial. The amount set aside should include amount of life insurance plus additional funds. A copy of that agreement should be submitted to the Business Office. 2. When all assets are reduced to $2,000.00, call the Business Office for appointment for guidance in the enrollment process. It is the legal responsibility of the POA/Representative Payee to complete the application and enrollment process for Medical Assistance benefits. Every effort will be made by our Business Office staff to assist you. A checklist (pg12-13) is being provided to you with guidelines that will help you get started. Please be aware however, that if the POA/Representative Payee does not follow through in a timely manner, that the Church of God Home, Inc. reserves the right to file the application on the resident's behalf. 3. The Centre County Office of Aging will do a level of care assessment of the resident, known as an "Options Assessment" and forward the results to the Pennsylvania Department of Public Welfare (DPW) for further follow-up by the Centre County Assistance Office. Should they assess for a different level of care other than nursing, and/or the resident does not qualify for Medicaid, the facility reserves the right to terminate the admission agreement and will work with resident/responsible party regarding available options. 9 4. To appeal a decision regarding a Medicaid Assessment, contact: The Pennsylvania Department of Public Welfare Huntingdon County Assistance Office (Cumberland County Long Term Care Unit) 7591 Lake Raystown Shopping Center Huntingdon, Pennsylvania 16652-0398 P: (814) 641-6447, 800-237-7674 Fax: (814) 6*5441 To appeal a decision regarding a level of care assessment, contact: The Cumberland County Office of Aging Long Term Care Program Human Service Building 1100 Claremont Road Carlisle, Pennsylvania 17013 (717) 240-6110 5. After preliminary papers are sent to the assistance office, the resident's security deposit will be applied to room and board and any balance due billed to the responsible party. 6. After being approved, Medicaid requires that the resident's monthly income be submitted to the facility each month. Of that amount, the resident will receive the approved $45.00 monthly allowance for his/her personal needs. The resident, responsible party or the facility may, handle this personal money: 7. Allowable expense from resident monthly income is health insurance. After acceptance into the Medicaid program, billing for health insurance should be forwarded to the staff in our business office. The monthly expense for this insurance is deducted from the resident's monthly income and the balance is applied to the room and board. The state pays the facility a per diem (daily) rate times the number of days in the month that a resident, approved for Medicaid, occupies an accommodation. After resident's responsibility is applied to this amount, the balance is billed to the Pennsylvania Department of Public Welfare (DPW) on a monthly basis. Bills for personal needs may be presented in the resident's name to the facility handling funds for reimbursement. Upon enrollment into the Medicaid program, the resident will no longer pay for routine hair care, incontinence supplies, non-emergent medical appointment transportation or personal laundry service. Medicaid will, however, pay for prescription drugs, doctor visits, dental services and eye examinations. 8. Upon transfer or discharge for hospitalization of a resident receiving medical assistance benefits, the facility will hold a bed. 10 r CHURCH OF GOD HOME "Committed to Caring" Medicaid (Medical Assistance) Residents 1. The Church of God Home, Inc. requires a copy of monthly / quarterly Medical Insurance premiums. As f. REQUIRE Qa$45.00 ylvania State Regulations. 2. Medical Ine ms will be deducted from the Resident's monthly income and the balance of the income lesallip ance wil l be applied to room and board. 3. Prescription„drugs, p?ysic' n visits, dental services, and eye examinations are covered by Medicaid, but only with parfickkad fists and ophthalmologists. Potential charges will be discussed with responsible party on an individual basis, when requesting non-participating providers. I 4. Services furnished at no charge to the Resident are as follows: ¦ Normal Shampoo every two weeks ¦ One perm every three months Transportation to and from medical appointments is provided (Distance to appointments will be discussed on an individual basis) • Non-emergent ambulance transportation • Personal Laundry • Incontinent Supplies j Bed hold in the event of hospitalization The following services will be charged: • Any hair care request beyond the above list of provided services • Transportation for a personal use • Telephone basic charges, and long distance changes 5. Bed hold days due to hospitalization will be fifteen (15) days per hospital stay. Bed hold days due to therapeutic leave will be thirty (30) days per calendar year. (Date) eParty) r (Resident Name (Facility Represent Medicaid (Medical Assistance) Resident's Checklist HUNTINGDON COUNTY ASSISTANCE OFFICE (Cumberland County Long Term Care Unit) 7591 Lake Raystown Shopping Center Huntingdon, Pennsylvania 16652.0398 Telephone: 1800.237.7674 or (814) 641.6447 In order to determine eligibility for nursing home Medicaid enrollment, the Centre County Assistance Office will need the following items to accompany your application when submitted by our billing office. (Photocopies are acceptable) Please call 9 you have any questions or need help in obtaining the required information. 1. Social Security Card(s) 2. Proof of Date of Birth _ 3. Health Insurance Cards A. Medicare (Red/White/Blue Card(s)) B. Capital Blue Cross / Highmark Blue Shield Card(s) C. Any other health insurance plan(s) - 4. Health Insurance Premiums, provide frequency and amount I -- 5. Long Term Care Policies, provide monies received and terms ____ 6. Power of Attorney or Guardianship papers 7. Read HIPPA disclosure and complete the HIPAA disclosure request PWi815 _ 8. Verification of ALL GROSS VA income needed. (If you are not receiving benefits, you will need to apply for potential benefits in order to be eligible for Medicaid.) + _ 9. Verification of ALL GROSS income - provide current award letters, pensions, annuity income, and interest income 10. Provide current statements for ALL bank accounts, stocks, bonds, trusts, IRAs, Keoghts, and Annuities - must provide values of 11. Personal Care Account (PGA) Balance r 12. Verification of all resources sold, transferred, or given away during the past 5years (5 years for a Trust Fund) - provide disposition, amounts, and dates 13, Titles, vehicle registration, and insurance for all vehicles owned, including boats, motorcycles, and trailers 12 14. Current cash value of all life insurance policies. Verification should include company's name, policy number, type of policy, face amount of policy when purchased, ownership of policy, and statement on the current cash value from the insurance company. 15. Deed to burial plot(s) or statement from cemetery 16. Copy of Burial Trust 1 Reserve (including Statement of Irrevocability) 17. Deed to all property and it's current market value - if transferred or sold within the last 5 years, provide a copy of the new deed and the settlement sheet for all sold property _ 18. Title to mobile home and its current market value - if transferred or sold within the last 5 years, provide a copy of the new deed and the settlement sheet for all sold property 19. Any unpaid medical bills you wish to see if Medical Assistance would cover _ 20. Rent / Mortgage payment proof 21. Utility Bills A. Electric B. Gas C. Oil D. Heat E. Telephone F. Water G. Sewer H. Trash _. 22. Income Tax Returns - for the past 5 years, provide all schedules and 1099 Forms E 13 MEDICARE The Church of God Home participates in the Medicare program administered pursuant to Title XVIII of the Federal Social Security Act. Medicare hospital insurance helps pay for inpatient care in a Medicare-participating skilled nursing facility following a three (3) night hospital stay and your condition requires daily skilled nursing or rehabilitation services which, as a practical matter, can only be provided in a skilled nursing facility. A skilled nursing facility is a specially qualified facility, which has the staff and equipment to provide skilled nursing care or rehabilitation services and other related health services. Hospital insurance helps pay for care in a skilled nursing facility if all of the following five conditions are met: 1. You have been in a hospital at least three nights in a row, before your transfer to a participating skilled i nursing facility. 2. You are transferred to the skilled nursing facility because you require care for a condition, which was treated in the hospital. i 3. You are admitted to the facility within a short time, generally within 30 days after you leave the hospital. 4. A doctor certifies that you need, and you receive, skilled rehabilitation services on a daily basis, and o 5. The Medicare intermediary or the facility's Utilization Review Committee does not disapprove your stay. All conditions must be met. It is especially important to remember the requirement that you must need skilled nursing care or skilled rehabilitation services on a daily basis. N Skilled nursing care means care that can only be performed by, or under the supervision of, licensed nursing { personnel. Skilled rehabilitation services may include such services as physical, occupational, and speech therapies performed by, or under the supervision of, a professional therapist. The skilled nursing care and skilled rehabilitation services you receive must be based on a doctor's orders. i Hospital insurance will not pay for your stay if you need skilled nursing or rehabilitation services only occasionally, such as once or twice a week, or if you do not need to be in a skilled nursing facility to get skilled services. When your stay in a skilled nursing facility is covered by Medicare, hospital insurance helps pay for up to 100 days each benefit period, but only if you need daily skilled nursing care or rehabilitation services for that long. 14 if you leave a skilled nursing facility and are readmitted within 30 days, you do not have to have a new 3- night stay in the hospital for your care to be covered. If you have some of your 100 days left and you need skilled nursing or rehabilitation services on a daily basis for further treatment of a condition treated during your previous stay in the facility, Medicare will help pay. In each benefit period, hospital insurance (Medicare Part A) pays for all covered services for the first 20 days you are in a skilled nursing facility. For the 21st through the 1001h day, as long as you continue to meet the criteria for daily Skilled Nursing Care or Rehabilitation Services, hospital insurance pays for all covered services except for $141.50 a day. You may be charged up to this amount by the skilled nursing facility or it may be picked up by your secondary co-insurance. Effective May 30, 2008: Medicare requires that each resident / responsible party indicate their choice with regard to a bed hold if any nursing resident is hospitalized. Major services covered when you are in a skilled nursing facility Medicare hospital insurance (Medicare Part A) pays for these services: • A semi-private room, 2 beds in a room • All your meals, including special diets • Regular nursing services • Rehabilitation services, such as physical, occupational, and speech therapy • Drugs furnished by the facility during your stay • Blood transfusions fumished to you during your stay ¦ Medical supplies such as splints and casts • Use of appliances such as a wheelchair • Oxygen usage Some services not covered when you are in a skilled nursing facility Medicare hospital insurance (Medicare Part A) does not pay for these services: • Personal convenience items such as a telephone in your room • Private duty nurses • Any extra charges for a private room unless it is determined to be medically necessary • Transportation • Name Labels • Hair Care • Personal laundry service NOTE: If you disagree with a decision on the amount Medicare will pay on a claim or whether Medicare covers services you receive, you always have the right to appeal the decision. Feel free to contact Medicare at 1-800-6334227. The Church of God Home reserves the right to withdraw from the Medicare program. 15 MOBILE X-RAY IMAGING, INC. Mobile X-Ray Imaging, Inc. (°MXI") is the most advanced, most efficient, most complete and the only local mobile diagnostic X-Ray/Ultrasound/EKG service in Central Pennsylvania. Based in Harrisburg, MXI employs technologists in Carlisle as well as both the East and West Shore areas of Harrisburg, making it convenient for us to provide fast efficient service to our customers throughout the region. We provide a broad range of mobile diagnostic services to our nursing home customers at the nursing facility, offering the convenience and comfort of having diagnostic studies performed in the home without the expense and discomfort of ambulance transportation. The following diagnostic services are available on 24 hours per day, 365 days per year basis: Diagnostic X-Ray Studies Electrocardiogram Services Holter Monitor EKG Diagnostic Ultrasound Examinations Our X-Ray and Ultrasound exams are interpreted by Quantum Imaging and Therapeutic Associates (formerly known as A.Z. Ritzman Associates), one of the foremost radiology physician practices in Central Pennsylvania. All EKG and cardiology related exams are interpreted locally by Associated Cardiologists, P.C. MXI has introduced the following significant improvements to the mobile diagnostic testing industry in Central Pennsylvania: MXI was the first provider to utilize sophisticated 'high frequency' portable X-Ray units, which produce superior images with less radiation exposure. • We were the first mobile service in Central Pennsylvania to provide 24 hours a day, 7 days a week X-Ray service with round the clock interpretations. We are the only mobile service in Central Pennsylvania, which does our own ultrasound examinations, which gives us complete control over quality and service efficiency. We are the only mobile service in Central Pennsylvania to provide ultrasound service on 24 hours per day, 7 days a week basis, including interpretations. Our services are covered by Medicare, Medicaid and most major insurances. Mobile X-Ray Imaging, Inc. - 5120 Lancaster Street - Harrisburg, PA 17111(717) 5614940 Psychiatrist The Church of God Home, Inc. offers psychiatric services specializing in geriatric services. Philhaven Hospital has contracted with the Church of God Home to provide on-site services for our senior adults. Billing for this psychiatric service will be as follows: • If the resident is private pay, Philhaven Hospital will bill Medicare first, then your supplemental insurance. If there is still a balance, then the responsible party will be billed. • If the resident is on Medical Assistance, Philhaven Hospital will bill Medicare first, then your supplemental insurance, and Medical Assistance third. There will be no bill to responsible parties. Feel free to contact Philhaven Hospital at (717) 270-2413 or 1-888-740-8211 if you need further clarification. We at the Church of God Home welcome this new dimension of expertise to our highly qualified staff. 16 Smoking Policy The Church of God Home does not permit smoking in any of our levels of care. Residents and visitors who smoke are asked to utilize the area provided outside the main entrance for this purpose. Employees and volunteers are not permitted to assist residents in meeting their smoking needs. It will be necessary for residents to get assistance from their family member and friends. All prospective residents will be informed of our Facility's smoking policy. Specialized Services If you have mental retardation, a physical disability, or other disability which occurred before the age of twenty-two (22), you may be eligible to receive support services that would help you to live with your family, in your own apartment, or in another community setting. You may also be eligible for specialized services. For more information, if you have mental retardation call Central Regional Office of Developmental Programs at (717) 772-6507. If you have another disability (other than mental retardation or mental illness) call United Disabilities Service at (717) 397-1841. If you have mental illness (other than dementia) and you do NOT need nursing facility services, you may be eligible to receive support services that would help you live in your own apartment, in a group home, or another community setting. For more information, call (717) 772-7490. If you are not satisfied with the response you receive, call the Disabilities Rights Network of PA at (215) 238-8070. Transportation Enrollment with the local ambulance service is not required, but is recommended. Not all medical appointments require ambulance stretcher transport and are often handled by our wheelchair lift van. Physician ordered medical appointments are to be scheduled through our nursing department with local physicians, as the Church of God Home does not normally transport to out-0f-town medical appointments. Family members will be contacted to determine their availability to provide transportation, or to serve as a companion to accompany residents during transport, throughout the appointment, and on the return trip. Medical consult sheets accompany residents to their appointments and often there is a need to adjust for a meal or medication routine. I Families providing transport are requested to follow the sign out procedures and are asked not to schedule follow-up appointments unless they are intending to provide the transportation, In either event, please be sure to inform the nursing department of the scheduled follow-up appointment. NOTE: Transportation provided by the facility will be at an extra charge. Please see "Chart of Cost" for fee schedule. 17 IN UNDERSTANDING RESTRAINT USE In order to protect our residents from harm or to promote them to a higher level of independence, it is sometimes necessary for us to use a physical restraint. Physical restraints are any manual method, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily and that restricts freedom of movement or normal access to the resident's body. Examples include: bedside rails, leg restraints, arm restraints, hand mitts, soft ties, wheelchair safety bars and geri chairs. These devices are NEVER used as a disciplinary action or for the convenience of the facility to control behavior. Restraints are initiated only after less restrictive measures, such as positioning pillow, pads, wedges, removable lap trays couples with appropriate exercises, or other "enabling" equipment, have been demonstrated to be insufficient. The least restrictive device would be then implemented following a specific doctor's order and/or a phone call to P.Q.A. / next of kin. The resident will then be reviewed in the next Restraint Reduction meeting. The following its a comparison of potential BENEFITS and RISKS of restraint use: Potential Benefits • Prevention of falls which might result in injury • Protection from other accidents or injuries • Medical treatment allowed to proceed without resident interference • Protection of other residents/staff from physical harm j . Increased feeling of safety and security Potential Risks • Accidental injury from the restraint • Chronic constipation • Incontinence • Pressure sores • Loss of muscle tone • Loss of balance • Reduced appetite, dehydration • Loss of independent mobility • Increased agitation • Symptoms of depression, withdrawal • Contractures • Reduced social contact is CHURCH Of GOD HOME "Committed to Caring" Advance Directive Policy It is God alone who opens the door to earthly life. It is God alone who has the right to close it. All ` experiences of life provide opportunities for evangelism, ministry, reconciliation and re-assessment of priorities. The Church of God Home recognizes the right of an individual to make and change decisions concerning their medical care in consultation with their physician. This includes the right to accept or refuse artificial means of sustaining life when these decisions are set forth in properly executed Advance Directives/Healthcare Guidelines. In no instance will the Church of God Home condone homicide, euthanasia, suicide or aided suicide. In the absence of advance directive, the care of the resident will be in accordance with currently accepted medical standards. Regardless of the resident's decision about life sustaining treatment, supportive and compassionate care for maximum comfort will be provided. These measures include, but are not limited to, oxygen, medication to relieve pain, food and fluids as tolerated, along with emotional and spiritual support. Should the occasion arise when a resident would refuse nutrition or medical supportive services with the intention of prematurely bring their life to an end, the Home would encourage and recommend counseling and evaluation. The family would be informed and, if a satisfactory resolution cannot be achieved as to the care of the resident, the Home would assist the family in the attempt to relocate the resident to another facility as soon as possible. I acknowledge that I have received a duplicate copy of the above Advance Directive Policy and have had provided the opportunity to ask questions relating to the same. I have also been offered the opportunity to complete an Advance Directive. -3-1A1 4 I 1 i I (Date) (Resident/Responsible Party) - AA (Resident Name) I/ A r (Facility Representativ 19 42 CHURCH OF GOD HOME "Committed to Caring" Complaint Procedure Policy: It is the policy of the Church of God Home to have a complaint procedure in place to identify and address concerns. Purpose: To assure the Home's Mission Statement is being upheld to its highest integrity. Procedure: 1. Any written or oral complaints presented by or on behalf of a Resident to the Church of God Home regarding care, operations, or management of the Home shall be directed to the Administrator of the facility. 2. If a resident wishes to make a written complaint but needs assistance, the Social Worker shall assist the resident in writing the complaint. 3. Within two (2) business days after notification of a written complaint, a status report will be provided to the complainant and/or designated person, explaining the steps that the Home is taking to investigate and address the complaint. 4. The Church of God Home shall ensure the Resident's safety if complaint identifies harm or potential harm. 5. Within seven (7) days after the notification of a written complaint, a copy of the written decision explaining the investigation findings and plans of action will be given to the complainant and/or designated person. 6. All complaints will be placed in a binder with the findings and plan of correction. The Pri I Adminiatminr will maintain the binder. -- Ih? j (Date) (ReWeAResponsible Party) f /?, C (Resident Name) V, Ara,I, AAc (Facility Representative) 20 CHURCH OF GOD HOME "Committed to Caring" DELEGATION OF RESPONSIBILITY FORM As a result of medical and/or physical condition or personal choice, residents find it difficult to understand and/or sign for their Resident's Rights and/or their Admission contract. Some residents, although not legally judged incompetent, may be found by a physician to be incapable of understanding these rights and contract information. Therefore, a resident may choose to designate an individual to act of their behalf by permitting them to sign the necessary forms indicating receipt of this information. r is medically/physically capable of (Name of resident) understanding Resident's Rights but designates this to: -'? (Date) (Residen esponsibie Party) f 4 &4??) (Resident Name) Vr A "I (Facility Representa6v 21 4M CHURCH OF GOD HOLE "Committed to Caring" LEGAL RIGHTS COMPLIANCE RESIDENTS AWARENESS COMMONWEALTH INFORMATION CENTER 402A Finance Building Harrisburg, PA 17120 Telephone: 1-800-932-0784 PENNSYLVANIA DEPARTMENT OF AGING 555 Walnut Street Harrisburg, PA 17101 Telephone: 717-783-7247 PENNSYLVANIA DEPARTMENT OF HEALTH DIVISION OF NURSING CARE FACILITIES HARRISBURG FIELD OFFICE 132 Kline Plaza, Suite B Harrisburg, PA 17104 Telephone: 717-783-3790 CUMBERLAND COUNTY AGING & COMMUNITY SERVICES OMBUDSMAN PROGRAM HUMAN SERVICES BUILDING 1100 Claremont Road Carlisle, PA 17013 Telephone: 717-240-6110 (Date) PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE HUNTINGDON COUNTY ASSISTANCE OFFICE (Cumberland County Long Term Care Unit) 7591 Lake Raystown Shopping Center Huntingdon, PA 16652-0398 Telephone: 814-641-6447 1-800-237-7674 MID PENN LEGAL SERVICES 401 East Louther Street Carlisle, PA 17013 Telephone: 717-243-9400 (ResidenVResponsible Party) (Resident Name) (Facility Represents 22 42 CHURCH OF GOD HOME "Committed to Caring" NON-DISCRIMINATION STATEMENT In accordance with applicable Federal and State civil right laws and regulatory requirements, you, as a resident of this facility, have the right upon admission: To be provided services at this facility and to be referred for services at other facilities without regard to your race, color, religion creed, handicap, ancestry, national origin, age or sex. • To file a complaint of discrimination if you feel you have been discriminated against on the basis of your race, color, religious creed, handicap, ancestry, national origin, age, or sex. Complaints of discrimination may be filed with any of the following: President/CEO Department of Health and Human Services Church of God Home, Inc. Office for Civil Rights 801 N. Hanover Street 3. 150 S. Independence Mail West Carlisle, PA 17013 Suite 372 Phone: (717) 249-5322 Philadelphia, PA 19106.3499 Phone: (215) 861-4441 Pennsylvania Human Relations Commission Harrisburg Region Office Riverfront Office Center 1101-1125 South Front Street, 5th Floor Harrisburg, PA 17104-2515 Phone: (717) 787-9784 Department of Public Welfare Bureau of Equal Opportunity Central Regional Office Rm # 223, Health & Welfare Bldg. P.O. Box 2675 Harrisburg, PA 17120-2675 Phone: (717) 783-3063 3 z1 /1 (Date) (ResidentlResponsible Party) R . 6 - jjt.=a; (Resident Name) - - _V1 Wz A& (Facility Representative) 23 Personal Cash Accounts (PGA) To establish personal cash account (PCA) at the Church of God Home, Inc., contact our Business Office (Henderson House). The following procedure shall be followed: 1. Sign the following authorization form to open an account 2. Deposit money by checks or cash - A receipt will be issued for cash deposits. 3. Daily withdraw maximum of $30.00 Dote: Regular business hours are 9:00 a.m. to 3:45 p.m., Monday through Friday, except holidays. Deposits The resident or family member / responsible party may deposit cash or checks either at our Business Office (Henderson House) or in our Lobby Front Office during regular business hours and of course, by mail. Personal cash accounts are only meant to provide casual spending money for residents. Disbursements The resident may come to our Lobby Front Office during business hours to request money. A resident charge slip is completed and the resident or family member / responsible party sign the disbursement slip Purchases for a resident may be made by family or designated person and a receipt should be submitted to our Business Office for each reimbursement from the resident's account, i.e. Ns, shoes, clothing, etc. PCA's are reconciled monthly to the bank statement. Interest paid by the bank is pro-rated to each account and deposited into each account accordingly. Quarterly statements are issued, along with a cover letter to be signed by the resident and returned to our Business Office. Each resident of the facility has the right to open a personal cash account (PCA). All accounts, regardless of the resident's status, are handled in the same manner. Upon the death/discharge of a resident, the account balance shall be returned to the executor of their Will or authorized representative of their Estate within thirty (30) days. 24 Personal Cash Accounts (cont.) 4Mb? CHURCH OF GOD HOME "Committed to Caring" Authorization to Handle Personal Funds .3.1g v (Date) -46- (ResidenUResponsible Party) F (Resident Name) I/ A r - (Facility Represen Depleted Funds When resident's assets reach $15,0W-00, family/responsible party should contact our Business Office immediately. Family member / res . arty will have to apply for Medical Assistance. Residents with no family member / responsible arty, o' . usiness Office will apply for Medical Assistance. l Residents will receive 45.00 ' onthly from their income for personal needs. Other monies may be ' deposited into each PCA, as the'resident or family member / responsible party desires. (Date) (R si esponsible Party) (Resident Name) (Facility Representati ) ? c 25 . CHURCH OF GOD HOME "Committed ro Caring" Personal Laundry Service This is to advise that the personal laundry will be outside (circle one) the facility. NOTE: These arrangements can be changed with notification to Social. Services or Charge Nurse. • Residents 1 Responsible Parties providing laundry services need to provide a container with a lid and box of plastic bag liners for the purpose of storing laundry. • Volunteers are available to assist with labeling clothing I personal items. Please contact Social Services or Charge Nurse. Dry cleaning and Afteration Services are not provided. No wool items are accepted. (Date) (ResidenVResponsibfe Party) (Rest nt Name) (Facility Representa6 26 Pharmacy Services Specialist in 28 South 2r ` Street Newport, PA 17074 Continuing Care Rx is proud to announce that we have been chosen to be the provider of choice for the pharmacy services at Church of God Home. The mission of Continuing Care Rx is to provide pharmacy services and programs that meet the ever-changing needs of our facilities and the residents they serve, ensuring continued quality care and positive outcomes in the most cost-efficient manner possible. Pharmacy services for Long-Term Care or Personal Care Residences are mandated by government agencies to offer additional services, which you may not have been accustomed to in a normal retail pharmacy. These additional services are designed to aid in your progress (or that of your loved one). We would like to highlight some of the services we provide to give you a better understanding of the many unique benefits we have to offer the residents we serve: ? Controlled Packaging System - Routine tabletlcapsule medications are packaged in a 30-day sealed blister card enabling nursing staff to administer medications in a controlled environment with extreme accuracy and safety. ? Medical Records - A medical records staff member maintains and prints monthly charts that are utilized by the caregivers, nursing staff and physicians, ? 24-Hour Emergency Service - If a situation occurs that requires the delivery of medications in an emergency; Continuing Care Rx has a pharmacist and driver on call 24 hours a day, 7 days a week to meet these emergency needs. ? Consultant Pharmacist - A Consultant Pharmacist is assigned to our facilities to review residents' charts on a monthly basis and to interact with the nurses and physicians to monitor the residents' condition. In addition, they will make recommendations to the physicians when a better and more cost- effective therapy for the existing condition becomes available. ? Delivery Service - Medications will be delivered to the facility at predetermined times on a daily basis, ensuring timely delivery of all medications ordered. ? Billing - The staff at Continuing Care Rx will handle the billing process for all types of reimbursement. Continuing Care Rx is a member of most insurance groups and we bill directly to these insurance groups. Should you belong to an insurance group with which we are not currently affiliated, we will immediately pursue enrollment in that program in an effort to meet your needs and ease your financial responsibility. We would like to point out that all of the above services are provided at no additional cost, thus ensuring a much more cost-effective and beneficial way of dispensing and monitoring our residents' medications. We, at Continuing Care Rx, are focused on providing the highest quality of pharmacy services to all of the residents we serve, We look forward to working closely with you (or your loved one) by providing the best service available in the long-term care industry. Note: Please contact Continuing Care RX with any questions or billing concerns at 1-800.675.2279. 27 Privary Nonce CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. 1. Our Duty to Safeguard Your Protected Health Information We are committed to preserving the privacy and confidentiality of your health information. We are required by certain state and federal regulations to implement policies and procedures to safeguard your health information. Copies of our privacy policies and procedures are maintained in our business office. We are required by state and federal regulations to abide by the privacy practices described in this notice, including any future revisions that we may make to the notice as may become necessary or as authorized by law. Individually identifiable information about your past, present, or future health or condition, the provision of health care to you, or payment for the health care treatment or services you receive is considered protected health information (PHI). Accordingly, we are required to provide you with this Privacy Notice that contains information regarding our privacy practices to explain how, when and why we may use or disclose your PHI and your rights and our obligations regarding any such uses or disclosures. Except in specified circumstances, we must use or disclose only the minimum amount of PHI necessary to accomplish the intended purpose of the use or disclosure of such information. We reserve the right to change this notice at any time and to make the revised or changed notice effective for PHI that we already have about you as well as any information we receive in the future about you. Should we revise/change this Privacy Nonce, we will promptly post the revision [insert location, such as on a websitel. You also may request and obtain a copy of any newlrevised Privacy Notice from the contact person identified on the last page of this notice. Should you have questions concerning our Privacy Notice, our contact information is listed on the last page of this document. 11. How We May Use and Disckm Your Protected Hearth IMormation We use and disclose protected health information for a variety of reasons. We have a limited right to use and/or disclose your protected health information for purposes of treatment, payment, or for health care operations. For other uses and disclosures, you must give us your written authorization to release your protected health information unless the law permits or requires us to make the use or disclosure without your authorization. Should it become necessary to release or give access to your protected health information to an outside party performing services on our behalf (e.g., maintaining our computers), we will require the party to have a signed agreement with us that the party will extend the some degree of privacy protection to your information as we do. The privacy law permits us to make some uses or disclosures of your protected health information without your consent or authorization. The following describes each of the different ways that we may use or disclose your protected health information. Where appropriate, we have included examples of the different types of uses or disclosures. These include: 1. Use and Disclosures Related to Treatment We may disclose your protected health information to those who are involved in providing medical and nursing care services and treatments to you. For example we may release protected health information about you to nurses, nursing assistants, medication aides/technicians. medical and nursing students, therapists, other pharmacists, medical records personnel, other consultants, physicians, etc. We may also disclose your protected health information to outside entities performing other services relating to your treatment; such as long term care facilities, hospitals, diagnostic laboratories, home healthlhospice agencies, family members. etc. 2. Use and Disclosures Related to Payment We may use or disclose your protected health information to bill and collect payment for items or services we provided to you_ For example, we may contact your insurance company, health plan, or another third party to obtain payment for services we provided to you. Pnvacv Notice 28 P7j1'QC9 .?'OtICt 3. Use and Disclosures Related to Health Care Operations We may use or disclose your protected health information for the performance of certain functions in monitoring and improving the quality of care and services that you and others receive. For example, we may use your protected health information to evaluate the effectiveness of the care and services you are receiving. We may also disclose your protected health information for auditing, care planning, quality improvement, and learning purposes. 4. Use and Disclosures Related to Treatment Alternatives, Health-Related Benetks and Services We may use or disclose your protected health information for purposes of contacting you to inform you of treatment alternatives or health-related benefits and services that may be of interest to you, such as a newly released medication or treatment that has a direct relationship to a treatment or medical condition. 111. Uses and Disclosures Requiring Your Written Audwrezation For uses and disclosures of your protected health information beyond the above excepted purposes, we arc required to have your written authorization, except as otherwise required or permitted by law. You have the right to revoke an authorization at. any time to stop future uses or disclosures of your information except to the extent that we have already undertaken an action in reliance upon your authorization. Your revocation request must be provided to us in writing. Our contact information for purposes of revoking your authorization is listed on the last page of this document. You may use our duthorizationfor Use or Disclosure of Protected Health Information form and/or our Revocation of an Authorization form to submit your request to us. Copies of these forms are available upon request. Examples of uses or disclosures that would require your written authorization include, but are not limited to, the following; I . A request to provide your protected health information to an attorney for use in a civil litigation claim. 2. A request to provide certain information to an insurance or pharmaceutical company for the purposes of providing you with information relative to insurance benefits or new medications that may be of interest to you. 3. A request to provide Piil to another individual or facility, where no exception from the written authorization requirement applies. IV. uses or Disclosures of Information Based Upon Your Verbal Agreement In the following situations, we may disclose a limited amount of your protected health information if we provide you with an advance oral or written notice and you do not object to such release or such release is not otherwise prohibited by law. However, if there is an emergency situation and you are unable to object (e.g., because you were not present or you were incapacitated), disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be in your best interest When a disclosure is made based on these or emergency situations, we will only disclose protected health information relevant to the person's involvement in your care. For example, if you are having an adverse reaction to a medication, and are not able to communicate with us effectively, we may inform a family member involved in your care of your drug regimen and possible side effects. You will be informed and given an opportunity to object to further disclosures of such information as soon as you are able to do so. We may disclose your protected health information to your family members and friends who are involved in your care or who help pay for your care. We may also disclose your protected health information to a disaster relief organization for the purposes of notifying your family and/or friends about your general condition, location, and/or status (i.e., whether you are alive or dead). You may object to the release of this information. You may use our Request to Restrict the Use or Disclosure of Protected Health Information form to notify us of your objection or your objection may be made orally. Our contact information is listed on the last page of this document. (Sex also Section VI, paragraph 1.) V. tines and Disclosures of Information That Do Not Require Your Consent or Authorbadon State and federal laws and regulations in some instances either require or permit us to use or disclose your protected health information without your consent or authorization. The uses or disclosures that we may make without your consent or authorization include the following: 1. When Required by Law: We may disclose your protected health information when required by federal, state or local law. Privacy Notice 29 Privary.vaice 2. Abuse, Neglect, or Domestic Violence: As required or permitted by law, we may disclose protected health information about you to a state or federal agency to report suspected abuse, neglect, or domestic violence. If such a report is optional, we will use our professional judgment in deciding whether or not to make such a report. If feasible, we will inform you promptly that we have made such a disclosure. 3. Communicable Diseases: :"o the extent authorized by law, we may disclose information to a person who may have been exposed to a communicable disease or who is otherwise at risk of spreading a disease or condition. 4. Disaster Relief: We may disclose protected health information about you to government entities or private organizations (such as the Red Cross) to assist in disaster relief efforts. 5. Food and Drug Administration (FDA): We may disclose protected beahh information about you to the FDA, or to an entity regulated by the FDA, in order, for example, to report an adverse event or a defect related to a drug or medical device. 6. For Public Health Activities: As required or permitted by law, we may disclose protected health information about you to it public health authority, for example, to report disease, injury, or vital events such as death. 7. For Health Oversight Activities: We may disclose your protected health information to a health oversight agency such as a protection and advocacy agency, or to other agencies responsible for monitoring the health care system for such purposes as reporting or investigation of unusual incidents or to ensure that we are in compliance with applicable state and federal laws and regulations, including civil rights laws. S. To Coroners, Medical Examiners, Funeral Directors, Organ Procurement Organbadoos or Tissue Banks: We may disclose your protected health information to a coroner or medical examiner for the purpose of identifying a deceased individual or to determine the cause of death. We may also disclose your protected health information to a funeral director for the purposes of carrying out your wishes and/or for the fimeral director to perform his/her necessary duties. If you are an organ donor, we may disclose your protected health information to the organization that will handle your organ, eye or tissue donation for the purposes of facilitating your organ or tissue donation or transplantation. 9. For Research Purposes: We may disclose your protected health information for research purposes without your authorization only when a privacy board has approved the research project. We may use or disclose your protected health information to individuals preparing to conduct an approved research project in order to assist such individuals in iderttifjing persons to be included in the research project. Researchers identifying persons to be included in the research project will not be permitted to remove protected health information from our control. If it becomes necessary to use or disclose information about you that could be used to identify you by name, we will obtain your written authorization before permitting the researcher to use your information. Researchers will be required to sign a Confidentiality and Non-Disclosure Agreement form before being permitted access to protected health information for research purposes. A sample copy of this agreement may be obtained from our business office. 10. To Avert a Serious Threat to Health or Safety: We may disclose your protected health information to avoid a serious threat to your health or safety or to the beahh or safety of others. When such disclosure is necessary, information will only be released to those law enforcement agencies or individuals who have the ability or authority to prevent or lessen the threat of harm. 11. For Judicial or Administrative Proceedings: We may disclose protected health information about you in the course ofa judicial or administrative proceeding, in accordance with our legal obligations. Privacy Notice 30 Pr!•rncl' .ti'OtiCf? 12. To Law Enforcement: We may disclose protected health information about you to a law enforcement official for certain law enforcement purposes. For example, we may report certain types of injuries as required bylaw, assist law enforcement to locate someone such as a fugitive or material witness, or make a report concerning a crime or suspected criminal conduct. 13. Minors: If you are an unemancipated minor as defined under state law, there may be circumstances in which we disclose protected health information about you to a parent. guardian, or other person acting in loco paremis, in accordance with our legal and ethical responsibilities. 14. Parents: If you are a parent of an unemancipated minor. and are acting as the minor's personal representative, we may disclose protected health information about your child to you under certain circumstances. For example, if we are legally required to obtain your consent as your child's personal representative in order for your child to receive care or services from us, we may disclose protected health information about your child to you. In some circumstances. we may not disclose protected health information about an unemancipated minor to you. For example, if your child is legally authorized to obtain services (without separate consent from you), and does not request that you be treated as his or her personal representative, we may not be required to disclose protected health information about your child to you without your child's written authorization. 15. To Personal Representatives: If you are an adult or emancipated minor, we may disclose protected health information about you to a personal representative authorized to act on your behalf in making decisions about your health care. 16. For Specific Government Functions: We may disclose protected health information about you for certain specialized government functions, as authorized by law. Among these functions are the following: military command; determination of veterans benefits; national security and intelligence activities; protection of the President and other officials; and the health, safety, and security of correctional institutions. 17. For Workers' Compensation: We may disclose protected health information about you for purposes related to workers' compensation, as required and authorized by law. VI. Your Rights Regarding Your Protected HenHh Information You have the following rights concerning the use or disclosure of your protected health information that we create or that we may maintain about you_ 1. To Request Restrictions on Uses and Disclosures of Your Protected Health Information: You have the right to request that we limit how we use or disclose your protected health information for treatment, payment or health care operations. You also have the right to request a limit on the protected health information we disclose about you to someone who is involved in your care or the payment for your care or services. For example. you could request that we not disclose to family members or friends information about a medical treatment you received. Should you wish a restriction placed on the use and disclosure of your protected health information, you must submit sucb request in writing. Such request should be submitted using our Request to Restrict the Use and Disclosure of Protected Health Information form. Our contact information for purposes of making such a request is listed on the last page of this document. We are not required to agree to your restriction request. You will be informed if we decline your request. If we accept your request, we will comply with your request not to release such information unless the information is needed to provide emergency care or treatment to you. Privacy Notice 31 priwuy.ko" 2. The Right to Inspect and Copy Your Health and Billing Records: You have the right to inspect and copy your protected health information, such as your prescription and billing records. In order to inspect and/or copy your protected health information, you must submit a written request to us. if you request a copy of your prescription or billing information or other records, we may charge you a reasonable fee for the paper, labor, mailing, and/or retrieval costs involved in filing your requests. We will provide you with information concerning the cost of copying your protected health information prior to performing such service. Such requests should be submitted on our Request for Inspection/Copy of Protected Health Information form. Our contact information for such requests is listed on the last page of this document. We will respond within thirty (30) days of receipt of such requests. Should we deny your request to inspect and/or copy your protected health information, we will provide you with written notice of our reasons of the denial and your rights for requesting a review of the denial, if any. In the event of a review, we will select a licensed health care professional not involved in the original denial process to review your request and our reasons for denial. We will abide by the reviewer's decision concerning your inspection/copy requests. Your denial review request should be submitted on our Denial of Inspection/Copy of Protected Health Information form. Copies of these forms are available from the contact person listed on the last page of this document. 3. The Right to Amend or Correct Your Protected health information: You have the right to request that your protected health information be amended or corrected if you have reason to believe that certain information is incomplete or incorrect. You have the right to make such requests of us for as long as we maintain/retain your protected health information. Your requests must be submitted to us in writing. We will respond within sixty (60) days of receiving the written request, unless an extension is necessary, in which case you will be notified, and receive a response to your request within ninety (90) days. If we approve your request, we will make such amendmenWcorrections and notify those with a need to know of such amendments/corrections. We may deny your request if a. Your request is not submitted iv writing; b. Your written request does not contain a reason to support your request; c. The information was not created by us, unless the person or entity that created the information is no longer available to make the amendment; d. It is not a part of the protected health information kept by us; e. It is not part of the information which you would be permitted to inspect and copy, and/or f. The information is already accurate and complete. If your request is denied, we will provide you with a written notification of the reason(s) of such denial and your rights to have the request, the denial; and any written response (of reasonable length) you may have relative to the information and denial process appended to your protected health information. Your ameodmentlcorrection request should be submitted on our Request for AmendmenWarrection of Protected Health Information form. Copies of these forms are available from our business office. Our contact information for the purpose of making such a request is listed on the last page of this document. j l 4. The Right to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in a certain way or at a certain location. For example, you may request that we not send any protected health information to you at a health care facility, but instead send communication for you to a residential address or Post Office Box. We will agree to your request as long as it is reasonable for us to do so. You may submit your requests on our Request for Restriction of Confidential Communications form. Copies of these forms are available from the contact person listed on the last page ofthis document. Our contact information is listed on the last page of this document. 5. The Right to Request an Accounting of Disclosures of Protected Health Information: You have the right to request that we provide you with a listing of certain disclosures of your protected health information that we have made over a specified period of time. This accounting will not include any information we have made for the purposes of treatment, payment, or health care operations or information released to you, your Privacy Notice 32 Prn'Q^v Nonce family or friends for notification purposes, disciosures made for national security purposes or to certain law enforcement officials. incidental disclosures, disclosures made as part of a limited data set (for use in research, public health, etc.), or any disclosures made pursuant to your authorization. Your request must be submitted to us in writing and must indicate the time period for which you wish the information (e.g., May 1, 2003 through August 31, 2003). Your request may not include releases for more than six (6) years prior to the date of your request and may not include releases prior to April 14, 2003. Your request must indicate in what form (e.g., printed copy or email) you wish to receive this information. We will respond to your request with sixty (60) days of the receipt of your written request. Should additional time be needed to reply, you will be so notified. However, in no case will such extension exceed thirty (30) days. The first accounting you request during a twelve (12) month period will be free. There may be a reasonable fee for additional requests during the twelve (12) month period. We will notify you of the cost involved and you may choose to withdraw or modify your request at that time before any costs are incurred. You may submit your requests on our Request {or an Accounting of Disclosures of Protected Health /nformarion form available from our business office. Our contact information is listed on the last page of this document. 6. The Right to Receive a Paper Copy of This Notice: You have the right to receive a paper ropy of this notice even though you may have agreed to receive as electronic copy of this notice. You may request a paper copy of this notice at anytime or you may obtain a copy of this information from our websile (as applicable). Our contact information is listed on the last page of this document. V1. How to Film a Complaint About Our Privacy Practices if you have reason to believe that we have violated your privacy rights or our privacy policies and procedures, or if you disagree with a decision we made concerning access to your protected health information, you have the right to file a complaint with us or the Secretary of the U.S. Department of Health and Human Services. You will not be retaliated against 1 for filing acomplaint. You may submit your complaint on our Privacy Practices Complainj form available from our business office. Our contact information is listed on the last page of this document. 6 Aivary Noticr 33 Privac` Notice CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES n Acknowledgment Record of Acknowle on btai Name of IResidcntlPatient): uDate: Effective ]fate of This Privacy Notiee'Aprr114, 2003 Contact Information for Quesdons, Comptsints or Requests Regarding Yoor Health Information Should you have any questions concerning our prirx practices. obtaining a copy of our privacy notice. requesting restrictions on the release of your information, revoking an autboriZation, amrnding or cotrecting your protected health information_ obtaining an accounting of our disclosures of your protected health irtformatioo, requesting inspection or copying of your mcdieal information, requesting that we communicate information about your health matters in a certain way, filing complaints. or any other concerns you may have nslative to our privacy prat ices, please contact: Brian D. Stwagey Chief Compliance Ofter 5775 Allentown Blvd. Suite 202, Htnisburg, PA 17112 Tel: 717-810-1950 Ext. 4, Fes: 717-810-1952 bstvrWIW,4ccmorg If you wisk you may also file a complaint with the Secretary of the U.S. Department of Health and Haman Services. You may mail your complaint to U.S. Department of Health and Human Services, 200 Independence Avenue, S. W., Washington, DC 20201: or you may call (202) 619-0257 of 1-977.696-6775 (toll free); or you, may log on to the karrict address, htip:lhm w.hhs.grovlocr. Acknowledgment I Good Faith Effort to Obtain Aelknowliedgment (check one of the following) { j I am the above Resident/Patient and I certify that I received a copy of the Continuing Care Rx's Privacy Notice and that I have had an opportunity to review this document and ask questions to assist me in understanding my rights rt:iative to the protection of my health information. 1 am satisfied with the orplanaim provided to me and I am confident that Continuing Care Rv is committed to protecting my health information. Date: Signature: - Printed Namc: I 1 certify that I am the authorized representative of above name Resident/Patient and that I leave received the Privacy (( 'Notice on behalf of this individual and that Continuing Care Rx provided me with an opportunuty to review this document and ask questions to assist note in understanding the patimat's privacy rights. I on satisfied with the explanations provided to me and I am confident that the above-reamed entity is committed to protecting health information. %_ /1.. Dater Signature of Representative: Printed Name- . MIL Relationship io individual: r I J 1. . certify that I made a good faitfi 4ort to obtain the acknowledgment of the above- identified Irmideni/patient] or hisr'lter personal representative that hNshe had raxivcd a coley of the Privacy Notice of Cominuing Care Rx, but .vas unable to obtain such acknowledgment for the following reason(s): [ J [RcsidcntfttientJ or personal representative refitsed to sign t I IResiderNpaticrat] or personal r?egresetrtative was unavailable to sign. I 1 other: Date: SignaturrJTitle: Privacy Notice 7 34 CHURCH Of GOD HOME ''Committed to Caring" PODIATRY SERVICES I request that payment of authorized Medicare benefits be made either to myself, or on my behalf, to Dr. William Pulig for any services famished me by that physician. I authorize any holder of medical information about me to release to the Health Care Financing Administration and its agents, any information needed to j determine these benefits payable for related services. ,Yes, l have accepted Dr. William Pulig as my podiatry care physician No, I decline offered podiatry care physician for my podiatry care -,3-//4- (Date) (Resident/Responsible Party) iA? (Resident Name) (Facility Representative) 35 I CHURCH OF GOD HOME "Committed to Curing" Privacy Act Statement-Healthcare Records This form provides you the advice required by the Privacy Act of 1974. This form is not a consent form to release or use healthcare information pertaining to you. 1. Authority for collection of information including Social Security Number (SSN) Sections 1819 (f),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. This data is protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long Term Care System of Records. 2. Principal purposes for which 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 Medicare/Medicaid 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. 36 Privacy Act Statement-Healthcare Records (continued) The information collected will be entered into the Long Term Care Minimum Data Set (LTC MDS) system of records, System #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 Medicare/Medicaid 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 XVII I functions; and (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 Medicare/Medicaid 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 Medicare/Medicaid services. NOTE: Providers may request to have the Resident or their Representative sign a copy of this notice as a means to document that notice was provided. Signature is NOT required. If the Resident or their Representative agrees to sign the form it merely acknowledges that they have been advised of the foregoing information. Residents or their Representative must be supplied with a copy of the notice. This notice may be included in the admission packet for all new nursing home admissions. I (we) acknowledge receipt of the Privacy Act Statement - Healthcare Records _3-_11v-LL (Date) A -1Z (R le Party) (Resident Name) (FacilityRepresenta ' t 37 421b-a CHURCH OF GOD HOME "Committed to Caring" Private Room Policy - Nursing Policy: It is the policy of the Church of God Home that provisions shall be made for isolating a resident in a single room whenever their medical condition requires isolation. Purpose: To ensure that the resident receives the most suitable protection possible. Procedure: 1. The one private nursing room in this facility may be used as a regular private/single room until the facility's n or Isolation room arises. This room is identified as Room 118 Faith Wing. i \ti 2. Any resident using room 118 mint ree on admission that they will move out of the room to a semi-private room if the facility s to use it, 3. When a need for an isolation A ` arises and a semi-private room is not available at Church of God Horne, the resident occupying the private room will be transferred as soon as possible temporarily to another long-term care facility until a semi-private room becomes available at the Church of God Home. This individual will then be returned to the private room when it again becomes available. 4. Individuals interested in occupying a private room should make their interest known on admission to the Director of Admissions or their Social Worker at anytime. 1 5. The Director of Admissions will maintain a list of those residents interested in the private ` room. Such resident will be offered the private room, when available, based on their initial admission date to the Church of God Home, regardless of their level of care or the date they placed their name on the waiting list. 6. When not in an isolation need situation, a resident in the private room must be of private pay status. If no longer able to cover the monthly bill, such resident will be asked to relocate into a semi-private room as soon as an appropriate one becomes available at the Church of God Home. -141-11 (Date) (Resi sible Party) A It & V" 4"40-' (Resident ame) V, Af? 10 (Fadlity Representaty 38 4M1__ CHURCH OF GOD HOME "Committed to Caring" Therapy Church of God Home has arranged for Genesis Rehabilitation Services, a professional, full-service therapy company, to provide physical, occupational, and speech therapy services. These services will be provided only when the Resident's physician orders them, and when these services are necessary to attain or maintain the Resident's highest practicable physical, mental and psychosocial well being. While the payment of charges for therapy services is the responsibility of the resident, insurance will usually pay for such services. If the resident has Medicare Part B coverage, Medicare Part B will pay for 80% of the therapy charges. The balance of the 20% may be paid by the Resident`s supplemental insurance. In the event therapy services are not covered, the Resident will be billed privately. Residents should review the coverage for therapy under their plan, and, if necessary, call the insurance company. Residents / Responsible Party may contact our Business Office with questions related to therapy billing. Th d he co n o the prov ion of therapy services for ,.I//? z (the Resident) as ordered by Resident's p ician and deemed necessary to attain or maintain the highest practicable physical, mental and psychosociai well-being. The undersigned understands that no guarantee or assurance has been made as to any result that may be obtained from the Resident's treatment. The undersigned authorizes Church of God Home, Genesis Rehabilitation Services, and the Resident's treating or consulting physicians to release necessary records needed for the provision of therapy services or for payment. (Date) ) (Residen s+ble Party (Reside Name) (Facility Representative) 39 1 Vaccinations What is Influenza (Also Called Flu)? The flu is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness, and at times can lead to death. The best way to prevent the flu is by getting a flu vaccination each year. Every year in the United States, on average: . 5% to 20% of the population gets the flu; more than 200.000 people are hospitalized from flu complications; and about 36,000 people die from flu. Some people, such as older people, young children, and people with certain health conditions (such as asthma, diabetes, or heart disease), are at high risk for serious flu complications. Symptoms of Flu Symptoms of flu include: . fever (usually high) . runny or stuffy nose . headache • muscle aches . extreme tiredness +° Stomach symptoms, such as nausea, dry cough vomiting, and diarrhea, also can occur but • sore throat are more common in children than adults Complications of Flu Complications of flu can include bawl pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. How Flu Spreads i Flu viruses spread mainly from person to parson through coughing or sneezing of people with influenza. Sometimes people may became infected by touching something with flu viruses on It and then touching their mouth or nose. Most healthy adults may be able to intent others beginning 1 day before symptoms develop and up to 5 days after becoming sick. That means that you may be able to pass on the flu to someone else before you know you are sick, as well as whils you are sick. Preventing Seasonal Flu: Get Yac mated The single best way to prevent the flu is to get a flu vaccination each year. There are two types of vaccines: • The "flu shot" - an inactivated vaccine (containing killed virus) that Is given with a needle. The flu I shot is approved for use in people 6 months of age and older, including healthy people and people with chronic medical conditions. Page 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND Pncv NTION SAFER- HEALTHIER- PEOPLE" I i l? 40 Key Facts About Seasonal Influenza (Flu) • The nasal-spray flu vaccine - a vaccine made with five, weakened flu viruses that do not cause the flu (sometimes called LAN for 'Live Attenuated Influenza Vaccine'). LAN is approved for use in healthy' people 2-49 years of age who are not pregnant. About two weeks after vaccination, antibodies develop that protect against influenza virus infection. Flu vaccines will not protect against flu4ike illnesses caused by non-influenza viruses. When to Get Vaccinated Yearly flu vaccination should begin in September or as soon as vaccine is available and continue throughout the influenza season, into December, January, and beyond. This is because the ttrrsng and duration of influenza seasons vary. While influenza outbreaks can happen as early as October, most of the time influenza activity peaks in January or later. Who Should Get Vaccinated? In general, anyone who wants to reduce their chances of getting the flu can get vaccinated. However, certain people should get vaccinated each year either because they are at high risk of having serious flu-related complications or because they live with or care far high risk persons. During flu seasons when vaccine supplies are limited or delayed, the Advisory Committee on Immunization Practices (ACIP) makes reaomrnandations regarding priority groups for vaccination. People who should get vaccinated each year are: 1. People at high risk for complications from the flu, including: 3 • Children aged 6 monthr. until their 5th birthday, • Pregnant women, • People 50 years of age and older, People of any age with certain chronic medical conditions, and People who Nye in nursing homes and other long-term care fadities. 2. People who live with or care for those at high risk for complications from flu, including: i i Household contacts of persons at high risk for eomplIcadOM from the flu (see above), • Household contacts and out of home caregivers of children less than 6 months of age (these children are too young to be vaccinated), and Health care workers. 3. Children aged 6 months up to their 19* birthday 4. Anyone who wants to decrease their risk of influenza. Use of time Nasal Spray Flu Vaccine Vaccination with the nasal-spray flu vaccine is an option for healthy' people 249 years of age who are not pregnant, even healthy persons who live with or cane for those in a high-risk group. The one exception is healthy persons who care for persons with severely weakened immune systems who require a protected environment; these healthy persons should get the inactivated vaccine. Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER •HEALTHIER- PEOPLE" 41 PPIEUMOCOCCAL VACCI N E POLYSACCHARIDE WHAT YOU NEED TO KNOW - N., VAMM wi mm" Stownw" we ,. "to apmob"now rnpu M Sir "W*rP ftLWW & Why get vaccinated? 3 Who should get PPV? Pneumococcal disease is a serious disease that - All adults 65 years of age or older. causes much sickness and death. In fact, pneumococcal disease kills more people in the - Anyone over 2 years of age who has a long- United States each year than all other vaccine- term health problem such as: preventable diseases combined. Anyone can get - heart disease pneumocoecal disease. However, some people are - lung disease at greater risk from the disease. These include - sickle cell disease people 65 and older, the very young, and people - diabetes with special health problems such as alcoholism, - alcoholism heart or lung disease, kidney fat7ure, diabetes, HIV - cirrhosis infection, or certain types of cancer. - leaks of cerebrospinal fluid Pneumococcal disease can lead to serious infections of the lungs (pneumonia), the blood (bacteremia), end the covering of the brain (meningitis). About 1 out of every 20 people who get pneumococcal pneumonia dies from it, as do about 2 people out of 10 who get bac*eremtA and 3 people out of 10 who get meningitis. People with the special health problems mentioned above are even more likely to die from the diease Drugs such as penicillin were once effective in treating these infections; but the disease has become more resistant to these drugs, making treatment of pneumocoaal infections more difficult. This makes prevention of the disease through vaccination even more important. 2 Pneumot:occal polysaccharide vaccine (PPV) The pneumococcal polysaccharide vaccine (PPV) protects against 23 types of pneumococcal bacteria. Most healthy adults who get the vaccine develop protection to most or all of these types within 2 to 3 weeks of getting the shot. Very old people, children under 2 years of age; and people with some long-term illnesses might not respond as well or at all. - Anyone over 2 years of age who has a disease or condition that lowers the body's resistance to infection, such as: - Hodgkin's disease - lymphoma, leukemia - kidney failure - multiple myeloma - nephrotic syndrome - HIV infection or AIDS - damaged spleen, or no spleen - organ transplant Anyone over 2 years of age who is taking any drug or treatment that lowers the body's resistance to infection, such as: - long-term steroids - certain cancer drugs - radiation therapy - Alaskan Natives and certain Native American populations. Pneumococcal Polysaccharide 43 4 How many doses of PPV are needed? Usually one dose of PPV is all that is needed. However, under some circumstances a second dose may be given. • A second dose is recommended for those people aged 65 and older who got their first dose when they were under 65, if 5 or more years have passed since that dose. • A second dose is also recommended for people who: have a damaged spleen or no spleen have sickle-cell disease - have HIV infection or AIDS - have canoe; leukemia, lymphoma, multiple myeloms have kidney failure have nephrotic syndrome have had an organ or bone marrow transplant are taking medication that lowers immunity (such as chemotherapy or long-term steroids) Children 10 years old and younger may get this second dose 3 years after the first dose. Those older than 10 should get it 5 years after the irst dose. 5 Other facts about getting the vaccine • otherwise healthy children who often get or infections, sinus infections, or other upper respiratory diseases do not need to get PPV because of these conditions. * PPV may be leas effective in some people, especially those with Lower resistance to infection. But these people should still be vxcinated, because they are more likely to get seriously ill. from pru:amococal disease. Pregnancy: The safety of PPV for pregnant women has not yet been studied. There is no evidence that the vaccine is hmT ftd to either the mother or the fetus, but pregnant women should consult with their doctor before being vaccinated. Women who are at high risk of pneumowccal disease should be vaccinated before becoming pregnant, if possible. Less than 1% develop a fever, muscle aches, or more severe local reactions. Severe allergic reactions have been reported very rarely. As with any medicine, there is a very small risk that serious problems, even death, could occur after getting a vaccine. Getting the disease is much more likely to cause serious problems than getting the vaccine. 7 What if there is a serious reaction? What should t look for? • Severe allergic reaction (hives, difficalry breathing, shock). What should I do? • Call a doctor, or get the person to a doctor right away. ¦ TIM your doctor what happened, the date and time it happened, and when the vaccination was given. Ask your doctor, nurse, or health department to report the reaction by filing a Vaccine Adverse Event Reporting System (VAERS) form. Or you can file this report through the VAERS web site at www vaers.org, or by calling 1-800-922-7%7. VAERS dnet rmr provide medical advice. $ How can i learn more? • Ask your doctor or nurse. They an give you the vaccine package insert or suggest other sources of information. • Call your local or state health department. • Contact the Centers for Disease Control and Prevention (CDC): Call 1-800.232- 636 (1-8110-CDC-R00) or - Visit the National Immunization Program websire at www.edc.gov/vaccines $ What are the risks from PPV? PPV fs a very safe vaccine. About half of those who get the vaccine have very mild A DEf'Aa rmKXT CW MEALTH ANO MUMAN aaCllrlGlfi CENTERS FOR DISEASE CONTROL AND PREVENTION side effects, such as redness or pain where the shot is given. Pneumoeocca! Vilmne tnformtim Stuement 44 42? CHtI OF GOD FIE ME Tommitttd to Caring" Vaccinations The Church of God Home administers flu vaccine on an annual basis for all residents of our facility. Annually the Tri-Valent Influenza Vaccine will be offered, prior to the beginning of flu season, for all residents who provide written authorization themselves or by his/her responsible party. A resident cannot receive the Tri-Valent Influenza if they are allergic to eggs or egg products. Otherwise, the Tri- Valent Influenza has proven to be generally safe and effective. If you desire to receive the Tri-Valent Influenza vaccine and/or the pneumonia vaccine, please complete the authorization below. ? I do authorize that the Tri-Valent Influenza vaccine be given annually per facility protocol. ? No, l do not wish to receive the Tri-Valent Influenza at any given time. i ? I have received literature pertaining to the benefits of the Tri-Valent Influenza vaccine. The Church of God Home also offers a vaccine that provides effective protection against the Pneumococcal form of pneumonia. This vaccine will be available to those residents who desire it and are medically eligible. If you have any questions, you may discuss them with your personal physician r the Church of God Home physician who monitors your care. i ? I do authorize that the Pneumococcal Pneumonia vaccine be given. ? No, I do not wish to receive the Pneumococcal Pneumonia vaccine at any given time. ? I have received literature pertaining to the benefits of the Pneumococcal Pneumonia Vaccine. If known, please indicate the date when the vaccines listed below were last received: Tri-Valent Influenza vaccine: Pneumonia Vaccine: Tetanus ?Vajccine: (Date) 1 45 (Resident/Responsible Party) 4mb? CHURM OF GOD NOME "Committed to Caring" Valuables The Church of God Home desires to administer quality care for all of our residents, focusing on a high quality of life. We do want to avoid any unfortunate situation that could result in any financial or emotional loss to ( residents and/or families. Our Home has not had many such losses, but when they happen, it is tragic. To minimize the risk of loss, the Church of God Home recommends that residents have no more than five dollars 15.00)`at any one time in their possession or rooms, and keep no valuables, real or intrinsic, in their rooms. By signing to paper you acknowledge being informed of the Home's recommendations. Some people have wisely substituted 'Arcons for diamonds and kept the settings. It is the responsibility of the resident or the responsible party to havh items of value independently appraised and insured, if so desired to cover potential damage to or loss of personal property. If damage or loss occurs to the resident's property, the Church of God Home will investigate each incident of loss or damage to determine liability and assess depending on the facts and circumstances of each incident. The Church of God Home shall be responsible for only such losses or damages as are attributed by the Home due to the negligence of the Home. (Date) - VAZ) (Resider nsible Party) 1 (Resident N (Facility Representative) 46 CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMEN THIS AGREEMENT is made on this _& ay of , 20-LI, by and between the Church of God Home, Inc., called the "Facility," a Pennsylvania n- &tn I t at 801 N rth Hanover Street, sle, t?mbe d C y >y Penns vania, and called "Resident" and called "Responsible Party". The Resident and the Responsible Party reaffirm that the information provided in the Pre-Admission Questionnaire is true and correct and understand that the submission of false information may constitute grounds to terminate this Agreement. The Resident has applied for admission to the Facility and the Facility has approved the Application for Admission. Therefore, the Facility and the Responsible Party agree to the following terms: 1. PROVISION OF SERVICES - The Facility will provide Resident with: a. Skilled nursing care, i.e. professionally supervised nursing care and related health services under a plan of services regularly provided under a plan of care supervised by licensed personnel and, as required by the Resident's medical condition, assistance with activities of daily living. b. Accommodations consistent with the level of care provided to the Resident including heat, air conditioning, electricity, hot, and cold water. c. Bed, bedding, blankets, laundered bed linens, towels, and washcloths. d. Three meals each day except as otherwise radically indicated. e. Activity programs, Spiritual programs, and Social Services. 2. RECURRING CHARGES - in exchange for the above services, the Resident shall pay the following recurring charges: ?• c a. For skilled nursing care: $? dollars per day. 3. SECURITY DEPOSIT - The Resident shall pay the following non-recurring charges: a. A security deposit in the amount of thirty-one (31) times the current daily rate for the level of care required by the resident, will be billed after admission day. The amount of the security deposit is $ e. No interest will be paid on the security deposit. A security deposit will not be charged to { re idents who are receiving benefits for room and board provided by Medicare, until the Medicare benefit concludes. An applicant who is covered by Medicaid is not required to pay a security deposit. b. If the admission to Nursing Care is the result of a level of care change from Personal Care, the Resident will be billed the difference between the two Security Deposit rates. c. The security deposit for private pay residents, after deductions for the payment of any outstanding bills owed to the Facility, will be refunded within thirty (30) days after the Residents discharge or death. Upon discharge or death the following refund policy will be followed: i. Thirty (30) days - Private Pay ii. Ninety (90) days - Medicaid iii. Thirty (30) days - Personal Cash Account There will be no other refunds, in the absence of an over payment, under this Agreement. 4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES - Resident is responsible to pay for other services provided by the Facility, which are not covered by the daily rate/charge. A list of such services charges is attached to this Agreement on the "Chart of Costs." 47 Admission and Care Agreement- continued The services of a licensed physician and dentist, a registered pharmacist and licensed pharmacy for the provision of pharmaceutical supplies, a licensed hospital, and diagnostic services, will be made available at the Resident's expense. The resident has the right to select his/her own physician or any other service provider so long as the physician or other service provider is property licensed or registered under the law, and that all applicable government rules and policies of the Facility are met. In addition to the Facility's charges, the Resident is responsible to pay all fees and costs for goods or services furnished to or for the Resident by anyone other than the Facility under this Agreement. The responsibility of the Resident to pay applies to all fees for costs of services provided for the Resident by any physician, dentist, optometrist, therapist, diagnostic or resting laboratory, pharmacist, pharmacy, hospital, or any other person, facility or entity providing services or goods to or for the Resident, and for all drugs, medicines, medications, pharmaceutical supplies, corrective eye lenses, hearing aids, dentures, hair care, and other personal items or services for the Resident. Such fees and costs are not included in the Home's daily ratelcharge. 5. ADMISSION - The Resident will be admitted, or a bed will be reserved for Resident, beginning on All pre-admission charges will be billed after admission, and recurring charges will begin to accrue as of the above date. The Resident may reserve an available bed by paying the daily rate for the bed reserved. The daily rate for the reserved bed will continue to accrue and be payable until the reservation is terminated, even if the Resident does not enter the Home for whatever reason, including illness, injury, incapacity or death. 6. PERIODIC BILLINGS AND PAYMENT DUE DATE a. On the first of each month, Resident will be billed the current daily rate for Resident's current level of care times the number of days in the month. The bill is due and payable upon receipt. A service charge of one and one-half (1 '/z%) percent per month will be added to amounts past due in excess of thirty (30) days, and Resident, and if applicable, Responsible Person or Guarantor is obligated to pay any late charges. b. Miscellaneous charges (refer to "Chart of Costs' attached to this Agreement) such as hair care, personal laundry, incontinency, supplies, etc., are additional charges above the daily rate. These miscellaneous charges will be added to, and included with, your monthly bill. c. Pharmacy changes will be billed as a separate part of the Facility's monthly bill, and will require a separate check. d. Outside providers will bifl directly and separately. 7. CHANGES IN CHARGES- From time to time, the Facility may change the amount of its charges. In addition, from time to time, the Facility may change how and when its changes are computed, billed or become due. The Facility reserves the right to make any such changes at any time. Written notices of any such changes will be given to the Resident thirty (30) days in advance of implementation, unless the change is required earlier under any federal or state law or assistance program. 8. "MEDICARE/MEDICAID" PROGRAM - The Facility participates in the Medicare program administered pursuant to Title XVIII o f the Federal Social Security Act and the Medicaid (Medical Assistance) Program administered pursuant to the Pennsylvania state plan and Title XIX of the Federal Social Security Act. However, the Facility reserves the right to withdraw from the Medicare/Medicaid program at any time in accordance with the law. 48 Admission and Care Agreement. continued 9. OBLIGATIONS OF RESPONSIBLE PARTY - The Responsible Party is responsible for services and supplies that are billed through the Facility directly to the Resident, Responsible Party, or by any other provider. The Responsible Party is responsible to pay all fees and costs from Resident's resources. In the event of an emergency the Responsible Party is asked to leave an emergency contact telephone number (s). (i.e. when vacationing) 10. READMISSION - BED HOLD POLICY - If the Resident leaves the Facility for a period of hospitalization, therapeutic leave, or any other reason, other than the Resident's death, and if the Resident is not eligible for, or receiving medical assistance, the Responsible Party will be contacted to determine is the bed is to be held in reserve at the daily rate. If the Resident or Responsible Party elects not to reserve a bed, then the Resident will be eligible for readmission upon the availability of the first bed suitable for the Resident's level of care. If the resident is receiving medical assistance benefits and the Resident leaves the Facility for a period of hospitalization or therapeutic leave, the Resident's bed will be reserved for the applicable maximum number of days paid for the reserved bed under the Medicaid (Medical Assistance) Program. The current bed reservation period is fifteen (15) days for hospitalization, fifteen (15) days for therapeutic leave for residents receiving skilled nursing care, and thirty (30) days for therapeutic leave for residents receiving nursing care. The bed reservation period may be subject to change in accordance with any changes in the Medicaid (Medical Assistance) Program. If the period of hospitalization or therapeutic leave ends within the reservation period under the Medicaid (Medical Assistance) Program, the Resident may return to the Facility. If the period of hospitalization or therapeutic leave exceeds the maximum time for reservation of a bed under the Medicaid (Medical Assistance) Program, the Resident must wait until a suitable bed becomes available for readmission. The Resident is entitled to the first available bed suitable for the Resident's level of care if, at the time of readmission, the Resident requires the services provided by the Home. Effective May 30, 2008, Medicare requires that each resident / responsible party indicate their choice with regard to a bed hold if any nursing resident is hospitalized. ? Yes, I would request a bed hold. I understand that I will be billed at the standard daily rate. ? No, I not wish to hold a bed in the event of a hospitalization. I understand that by doing i e bed may no be available for readmission. o be determined at time of hospitalization. 11. REFUNDS - The security deposit for private pay residents, after deductions for the payment of any outstanding bills owed to the Facility, will be refunded within thirty (30) days after the Residents discharge Facility or death. Residents receiving Medicaid will receive a refund, if any due, within ninety (90) days. There will be no other refunds, in the absence of an overpayment, under this Agreement. 12. PERSONAL FINANCES - The Resident has the right to manage his/her personal funds. The Resident is and will be responsible to provide his/her personal funds. If the Resident elects, the Resident may designate, in writing, that the Facility hold and manage the Residents personal funds. If the Resident designates someone other than the Facility to manage his/her personal funds, the Resident or Responsible Party shall notify the Facility promptly. The Resident is not required to make any designation, and is responsible for his/her own personal funds unless such designation is made. 49 Admission and Care Agreement- continued The Resident may revoke, at any time, the designation of the Facility as the manager of his/her personal cash account by providing the Facility a written notice signed and dated by the Resident or Responsible Party. If the Resident transfers to the Home, responsibility to manage the Resident's personal funds, the Facility will do so in accordance with the "Rights of Nursing Facility Residents", a copy of which is provided at the time of your admission. The Facility may deduct, at any time, charges due the Facility under this agreement from the Resident's personal funds managed by the Facility. 13. TERMINATION, TRANSFER, DISCHARGE, OR LEAVE OF ABSENCE a. By the Resident: The Resident may terminate this Agreement upon thirty (30) days written notice to this Facility. If the Resident leaves the Facility for any reason other than a medical emergency or death, the Resident must give written notice to the Facility at least thirty (30) days in advance of the departure/transfer/discharge or termination of the Agreement. If advance written notice is not given to the Facility, there will be due to the Facility it's daily and other changes then in effect for the Resident's current level of care for the required thirty (30) day notice period. The charge applies whether or not the Resident remains at the Facility during the thirty (30) day period. b. By the Facility: The Facility may terminate the Resident's stay and transfer or discharge the Resident if: L The transfer or discharge is necessary to meet the Resident's welfare which cannot be met by the Facility; ii. The Resident's health or condition has improved sufficiently that the Resident no longer needs the services provided by the Facility; iii. The safety or health of individuals in the Facility is or otherwise would be endangered; iv. The charges or other amounts due the Facility under this Agreement have not been paid to the Facility or treated as paid to the Facility on the Resident's behalf the Pennsylvania Medicaid Program or Federal Medicare benefits under Title XVIII or v. The facility ceases to operate. The Facility generally will notify the Resident and Responsible Party or if none, a family member of legal representative of the Resident, if known to the Facility, at least thirty (30) days in advance of such a transfer or discharge. However, in any case, described in subparagraph (i), (ii) or (iii) above, or if the Resident has not resided at the Facility for at least thirty (30) days, the Facility will give such notice before transfer or discharge as is practicable under the circumstances. 50 Admission and Care Agreement- continued 14. THIRD PARTY PAYMENTS - The Resident may be or may become eligible to receive financial assistance, reimbursement or other benefits from third-parties, such as through private insurance, employee benefit plans. Medical assistance under the Pennsylvania Medical Assistance Program, Medicare benefits, supplementary medical or other health insurance, supplemental security income insurance, or old age survivors' or disability insurance under or pursuant to the Federal Social Security Act or Program. If the Resident becomes eligible to receive payments from any third-parties for the stay and care of the Resident, the Resident/Responsible Party shall, at all times, cooperate fully with the Facility and each third-party payments. Cooperation includes, when requested, providing information, signing and delivering documents, and having the Facility designated by the Social Security Administration as the Resident's representative payee for receipt of Federal Social Security benefits or any other governmental assistance, reimbursement or benefits to the extent of all charges due the Facility. The Resident irrevocably authorizes the Facility to make claims and to take such other actions as maybe necessary for the Facility's receipt of third-party payments. To the fullest extent permitted by law, the Resident hereby assigns now or hereafter payable to the extent of all charges due to the j endorse and turn over to the Facility any payments received from third-parties to the extent necessary to satisfy the charges under this Agreement. 15. PERSONAL PROPERTY- The Resident/ Responsible Party is and will be responsible to furnish and maintain clothing, jewelry, personal possessions, and other items of property. The faciktty may limit the amount or type of property that the Resident may keep at the facility if there is insufficient space, or if medically indicated or necessary to protect the rights or welfare of others. All non-clothing items of value must be recorded on the resident's personal inventory located with their medical record on the day of admission or any day thereafter. The same is true if removing an item of value from the resident's room. You are requested to see the charge nurse / social worker regarding resident's personal property. If clothing needs labeled, please leave them at the nursing station. 1E. RESPONSIBILITIES OF RESIDENT- The Resident shall comply fully with all governmental laws and regulations, the provisions of this Agreement and the facility's existing policies, rules and regulations which may, from time to time, be altered or amended. 1 is MISCELLANEOUS PROVISIONS a. The Resident and Responsible Party acknowledge that they are adult individuals and have read and understand the terms of this Agreement. b. The provisions of this Agreement shall be governed by the laws of the Commonwealth of Pennsylvania and shall be binding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigned. c. The various provisions of this Agreement shall be severable one from another, If any provision of this Agreement is found by competent legal authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been part of this Agreement. 51 Admission and Care Agreement- continued d. The Facility reserves the right to modify unilaterally the terms of this Agreement to conform to subsequent changes in the law or regulation and changes in charges. Resident will be provided thirty (30) days written notice of changes in charges and, if practicable, reasonable notice of any modifications required by law. (Date) (Resident/Responsible Patty) c. (Resident N ?' A riza &&j (Facility Representative k-'? II 0 52 RESIDENT 1 FAMILY GUIDE TO INQUIRIES AND INFORMATION 0 0) PA a H = C7 E l6 C1 !D U :+ is 'D C N 20 IA _ C +' i U CD go tll C O w ?, d U L- r Inquires C jp V ? m E =C ?? R o a=E 5Z O !a d 3 m as O O a? O Q i xco M 0 U- C) Or: Nce z0 it w >0 Healthcare Personal Care X Admissions ' Independent Living x Admission ` Billing Question x i Medicare X Question Applying for x Medicaid ! Pharmacy Billing X I Laundry Billing x i Donation Monetary x Donation Other X 1 Personal Cash Account x Questions Personal Cash Deposits/ X Withdrawals Guest Meal i Reservations X Party Reserving of Lounge X i Family Concerns X HIPPA Changes X Coordinate Change in Level of Care X Resident Lost Items X Telephone Cable X Hook-up LeTort X Guest Suite 53 RESIDENT i FAMILY GUIDE TO INQUIRIES AND INFORMATION o tM C C N +- i m?E Inquires .c ° m m d° v o d o xcc m0 U ?0 0M 2? z0 w < cr?cn >o Change in Laundry Service x Transport Requests x x Special Hair Care Requests, Payment Scheduling x Resident Care ' x Resident Medication x Physician Questions x Therapy Questions x Taking Residents Out of Facility }( Change in POA Contact x Address /Phone Change in POA x Health Insurance Cards X Religious Questions x Funeral Questions X Funeral Procession Service x Memorial Services X "The Orchards" at Marsh Run x { 54 Facility Mailing Address: Facility Main Telephone #: Facility Administrator:............. 801 North Hanover Street Carlisle, PA. 17013 (717) 249-5322 Susan Bower, NHA ................................................................ ext. 3086 Activity Dept.: ? ........ ..Amy Findon, CTRS ................................................................. ext. 3021 (Director of Activities) -4 Business Offi Sharon Cramer (Business Office 1 Henderson House) ........................ ext. 3032 (Sr. Billing AIR Specialist - Personal Cash Accounts) ? .............. Michele Shughart (Business Office I Henderson House) ...................... ext. 3095 1 (Billing Specialist - Medical Assistance) Care P . 3033 lan: -tf ? ..............Lynne She!lenberger, RN (Mtg. win i4 days of Admission Ct (Nursing Assessment Coordinator - RNAC) Chaplain. ? ............. Pastor Bradley Moore............................................................. e)d. 3022 Dieta : ? .............. Bradley Weiser....................................................................... ext. 3966 (Director of Dining Services) Hair Care: ? .............Joan Ludwig......................................... ..............................ext. 3003 (Director of Hair Care) MedicalAppts.• ? .............. DavaBeltz.............................................................................. ext:3961 (Nursing Administrative Assistant) NursMary Hartman, RN, BSN .......................... ..... ext. 3015 r j? 1 Director of Nursing) ............Faith Long Halt (#103-? ?s} .................................................. xt. 309 ? .............. Faith Short Hall (#99,100-102,117-126) ...................................... ext. 3010 ? .............Love 1 (#201-215) .................................................................. ext. 3024 ? ............. Love 11(#217-239) ..................................................................... ext. 3025 ? .............. Beth Thumma, LPN................................................................ ext. 3012 (Personal Care Administrator), (Hope, Peace and Creekside Apt.) Pharmacy: . ntlnuin Care RX .....................................................1-800-675-2279 Social Services: ............Erin Naylor, MSW ............................................................. .!ext. 3084 (Director of Social Services) ? ..............Ellen Myers, BSW................................................................... ext. 3023 (Social Worker) Therapy Dept.: ? ..............Genesis Rehabilitation Services............................................. ext. 3017 Volunteer Office: ? ..............Linda Waggoner.... (Director of Volunteers) Physic - 55 .................................................. ext. 3028 Telephone#: ,? 19 Checklist - Nursing Care 1. CO LETEI COPY: ADVANCED DIRECTIVES/(gti6, . I TAMBULANCE CARD --E!rCONG-TERM. CARE INSURANCE POLICY ARD WER OWTORNEY OF GOD HOME, INC. L? "SHEET, iNSU CARDS VERIFIED ME ICE UPPLEMENTAL ? RX ? OTHER 2. REVIEW AND INFORM: ADMISSION AND CARE AGREEMENT ADMISSIONS POLICY ADVANCE DIRECTIVE POLICY AMBULANCE CHART OF COSTS COMPLAINT PROCEDURE DELEGATION FORM DEPLETED FUNDS DIETARY SERVICES DVD ACKNOWLEDGEMENT GUEST ROOM LEGAL. RIGHTS COMPLIANCE MEDICAID MEDICARE MISSIONNISION STATEMENT NON-DISCRIMINATION STATEMENT PERSONAL CASH ACCOUNT PERSONAL LAUNDRY P-MWALSECURITY CARD 2 VACCINE INFORMATION FORM ? 0TH '. JTO BUSINESS OFFICE COPIES TO DEPARTMENTS ??fl RESIDENT PY TO RESPONSIBLE PARTY PHARMACY AGREEMENT PODIATRY PRIVACY ACT STATEMENT PRIVATE ROOM POLICY PSYCHIATRIST RESIDENT / FAMILY GUIDE RESPIRATORY CARE SMOKING POLICY SPECIALIZED SERVICES SPOUSAL RESOURCE ASSESSMENT THERAPY SERVICES TRANSPORTATION UNDERSTANDING RESTRAINT USE VALUABLES WELCOME DIRECTORY WELCOME LETTER X-RAY ? OTHER I acknowledged that I have received the above information and have been afforded the opportunity to ask questions. s- l!q- t( jiodle (Date) (R Lnsible Party) It 56 EXHIBIT"C" (TO COMPLAINT) Notice ID: 9006348598 CUMBERLAND CAD 33 WESTMINSTER DRIVE CARLISLE, PA 17013-9976 of, pennsyLvania J?7,4=;'1;1Erl1' C7i- P;,3= tC: ',ticlrAi?r Mail Date: 1112912011 OFFICE OF INCOME MAINTENANCE Record ID: 21/0183127 Telephone: 1-800-269-0173 CHURCH OF GOD HOME Notice ID: 9006348598 801 N HANOVER ST COMPASS: The fast and easy way to apply for benefits CARLISLE, PA 17013-1599 www.gompass ate.pe,us n AILED ICt95 % ?,"w• v4 J.- By DEAR CHURCH OF GOD HOME, y You have been designated to receive a copy of Ib notice on behalf of Ruth ublin (850286141). . Please read further for details. Which benefit? This is a summary of your benefits. You can find more information inside this letter. Medical Assistance Your eligiblity for benefits has been reviewed and you do not qualify for Medical Assistance because. the value of your resources is too high. Read this letter for more in ma on. If you do not agree with this decision, read the flier that came with this letter called "Your Right to Appeal and to a Fair Hearing," Fill out the Fair Hearing form, then mail it or give it to your caseworker by December 29, 2011. Long Term Care You do not qualify for payment of services in a Long Term J Care facility because the value of your resources Is too high Read this letter for more nformation. h if you do not agree with this decision, read the flier that came with this letter called 'Your Right to Atppeal' and to a Fair Your benefit Information is continued on the next {gage.. If you have a disability and need this letter in large print or another format, please call our helpline at 1-800-692-7462. TDD Services are available at 1-800-451-5886. If you do not agree with our decision, you have the right to a Fair Hearing. To learn more about Fair Hearings, read Your Right to Appeal and to a Fair Hearing. Do you need legal help? You can get free legal help by visiting: ter,. MIDPENN LEGAL SERVICES at 401-405 L{OUTHER STREET, CARLISLE, PA 17013 or by calling (717) 243-9400. Record ID: 21/0163127 Mail Date: 11/2V2011 Page 1 of 8 PA 182 *900634859830000104* Notice ID: 9006348598 Which benefit? This is a summary of your benefits. You can find more information inside this letter. Hearing." Fill out the Fair Hearing form, then mail it or give it to your caseworker by December 29, 2011. 3- i Record ID: 2110163127 Mail Date: 11129/2011 Page 2 of 8 Past Notice ID: 9006348598 Your Medical Assistance Benefits Who does not qualify? Who? When? RUTH July 01, 2011 -July 31, 2011 This is the law we used to make this decision: 55 Pa. Code § 178.1 RUTH: (0710112011-07/31/2011) Your countable resources are over the resource limit. If you do not agree with this decision, read the flier that came with this letter called "Your Right to Appeal and to a Fair Hearing." Fill out the Fair Hearing form, then mail it or give it to your caseworker by December 29, 2011. `T Long Term Care Who does not qualify? Who? RUTH When? July 01, 2011 - July 31, 2011 t This is the law we used to make this decision: 55 Pa. Code § 178.1 RUTH: (0710112011-07/31/2011) You do not qualify for payment of services in a tong Term Care facility because you do not qualify for Medical Assistance. If you do not agree with this decision, read the flier that came with this letter called "Your Right to Appeal and to a Fair Nearing." Fill out the Fair Hearing forms then mat{ rt.or gyve AV your caseworker by December 29, 2011 ? Record ID: 2110163127 Mail Date: 11129/2011 Page 3 of 8 PA 162 *900834859830000204* Notice !D: 9006348598 Record ID: 21/01(:3127 Mai( Date: 11129/2011 Page 4 of 8 PAiS2 Notice ID; 9006348598 Your Right to Appeal and to a Fair Hearing What does right to appeal: mean? Cali the Statewide Your right to appeal means that you have the right to ask us to review our decision, if you Customer Service think that we made a mistake. You can ask us to review our decision at a fair hearing. Center at 1-877-395-8930. What is a fair hearing? A fair hearing is a meeting where you, the county assistance office (CAO), and a judge can In Philadelphia, talk about your appeal. call 1-215-560-7226. How can you ask for a fair hearing? You can call the GAO to ask for a fair hearing if you get a letter telling you about a The call is free decision that you think is wrong. If the decision is for Cash Assistance, Medical Assistance, . Call Monday to Low Income Home Energy Assistance Program (LIHEAP) or State Supplementary Friday from 8 a.m. Payment (SSP), you must also complete the attached Fair Hearing Form. If the decision is to 5 P.M. for SNAP (Food Stamps) fill out the form and send it to us. You do not have to do this, but its easier for us to track your appeal If you do. When can you ask for a fair hearing? You can ask for a fair hearing if you apply for benefits and you get a letter saying you do not qualify, or • you get a letter saying that your benefits will stop or change, or • you do not agree with the amount of your benefit. Do you need legal help? You can get free legal help by visiting M#DPENN LEGAL SERVICES at 401-405 LOUTHER STREET CARLISLE, PA 17013 or by calling (717) 243-9400. '1?4{ 2 1?? P• VV- '? . Choose the kind of fair hearing you want: • A telephone hearing at a place you choose. Tell us which phone number to use, such as your own, or a friend or relative's phone number, If you choose this kind of haring, make sure we can reach you at this phone number. The judge will call you and everyone in your cases, such as your witnesses, anyone helping you, and the county assistance office (CAO). • A telephone hearing at the CAD. You will go to the CAO for your hearing. iw The judge will call you there in the office, and call anyone helping you. • A face-to-face hearing with everyone in the hearing room. You can choose to have your hearing in Erie, Harrisburg, Philadelphia, Pittsburgh, Plymouth, or Reading. 1p? The judge, you, CAO staff, witnesses and anyone helping you will be in the room. • A face-to-face hearing with some people in the hearing room and some people on the phone. You can choose to have your hearing in Erie, Harrisburg, Philadelphia, Pittsburgh, Plymouth, or Reading. You and anyone helping you will be in the hearing room with the judge. The CAO staff will be on the phone. N.MEMMMM EM PA/FS 162 F V10 Record ID: 2110163127 Mail Date: 11129/2011 Page 5 of 8 *900634859830000304* Notice ID: 9006348598 2, Fill out the form on the last page. 3, Mail the form to: CUMBERLAND CAO, 33 WESTMINSTER DRIVE CARLISLE, PA 17013-9976 or give this form to the CAO. • For Cash Assistance, Medical Assistance, or SS,P, you must mail or give the form to the CAO within 30 days of the mailing date on your letter. • If you are applying for SNAP and you do not agree with the decision, you must mail or give the form to the CAO within 90 days of the mailing date on your letter. • If you already get SNAP and you do not agree with the decision, you must mail or give the form to the CAO within 90 days of the first day of the month that, your benefits change. • For LIHEAP you must mail or give the form to your CAO within 30 days of the mailing date on your letter. Can you talk with us before the fair hearing? Yes. You will get a letter from the CAO asking if you want to meet before the fair hearing takes place. A meeting before the hearing is called a pre-hearing conference. This meeting will not delay or replace your fair hearing. You can use this meeting to tell us if you have information that you think might change our decision. You can bring someone to speak for you if you want to. Can you get a copy of any information we used to make our decision? Yes, you can ask for a copy of all the documents that will be used at the hearing, Who can come to the hearing? You can bring anyone to the hearing, such as witnesses who might. have information. You can speak for yourself or bring someone to speak for you who knows more about the rules of the program. What If you speak another language,.are:deaf or have,.another disaia9ity? ' You can ask for an interpreter or other assistance to be at the Wir hearing on the attached Fair Hearing Form. This is a free service. You may bring a friend" or relative to help you at the hearing, but the Department will provide the official interpreter. At the Hearing Calf the Statewide Customer Service Center at 1-877-395-8930. In Philadelphia, call 1-215-560-7226. The call is free. Gall Monday to Friday from 8 a.m. to 5 p.m.. Remember: You must ask for i fair hearing within 13 days of the mailing date on your letter, if you want your benefite to stay the same while you wait for your hearing. What happens at,a fair hearing? 1. The CAO will tell you and the judge how they made their decision. You rmay ask questions. 2. You will have. time to tell the judge your side of the case, Someone can speak for you (if you want), and your witnesses can speak. You may show documents to the judge. 3. The judge may ask questions. When will you know what the judge decides? The judge will send you the decision within 90 days (within 60 days for SNAP (Food Stamps)) of the day you asked for the hearing. What happens if the judge decides the CAO is right? If the judge decides that the CAO made the right decision, your benefits will change or stop. ? You may have to pay back some or all of the benefits you got while waiting for your hearing. What if you do not agree with the judge's decision? You can appeal again. The judge's decision letter will tell you how to appeal. Record ID: 21/0163127 Mail Date: 11/29/2011 Page 6 of 8 NoticelD: 9006348598 "a r leaning Form p a 1. Name: CHURCH OF GOD HOME Case Number: 21/0163127 Phone number: Address: 801 N HANOVER ST I M S CARLISLE, PA 17013-1599 2. Tell us which program you want to appeal; 0 Other 3. Choose the way you want your hearing: By telephone, at the phone number you write on this form ? By telephone, at the CAO. ? Face-to-face, with CAO staff and a judge in the hearing room. ? Face-to-face, with you and the people you bring in the hearing room with a- judge and CAO staff on the phone. 4. Do you need a free interpreter? 0 Yes ZNo 11 Call the Statewide Customer Service Center at 1-877-355-8930. In Philadelphia, call 1-215-550-7226. The call is free. Call Monday to Friday from 8 a.m. to 5 P.M. R yes, what language? S. If you will need help at the appeal because of a hearing impairment or other disability, please tell us how we can help you. There is no cost to you for this service. 6. Tell us why you 7. Signature: 8. Date: 1?`i Ct?V? f t 9. Representative Name;?L??l ti ^ 'l Qtr' ? Cs ? 10. Representative Address: PUN 4 = r1 iPr y\ i . li f k 11. Representative Telephone Number:- n- LL4-q,-(;?, )( The Bureau of Hearings and Appeals will send you a letter to tell you when anakyhere your hearing will be. PA1FS 182 F 2110 P? 0, Record ID: 21/0163127 tv,ail Date: 1112912011 Page 7 of 8 *900634859830000404* EXHIBIT "D " (TO COMPLAINT) out ui nuarings-r-kppeais 2330 Vartan way Second Floor Harrisburg PA 17110-9946 NOTICE OF HEARING DATE AND TIME ?W'.0i pennsy'Nania DEPARTMENT ! F PU3L:C WELFARE Bureau of Hearincs & Appeals Phone: (717) 783-3950 Fa): (717) 772-2769 Dale February 23, 2012 Ivana Grujic Schufjer Bogar 309 Fellowship Rd Suite 200 Mt Laurel NJ 08054 Appellant Name and Adlress: Ruth C. Aubin Church Of God HOME 801 N Hanover St Carlisle PA 17013 Case No: 210163127-001 RE: NOTICETYPE: PPJFS 162F DATE OF NOTICE: 11/29/11 Dear Ms. Aubin: NOTICE ID: 9006348598 This acknowledges your request for a fair hearing from a decision by the Cumberland CAO concerning Nursing Home Denial, All Actions, A telephone hearing has been scheduled for you. The Administrative Law Judge will call you at the telephone number you provided on your appeal at the date and time specified below. Please notify my office immediately if this number has changed or is incorrect, or if you want a face-to-face hearing in Harrisburg. Hearing Date: March 14, 2012 Time: 10:00 a.m, You will be called at: (856) 533-2464 Administrative Law Judge (ALJ); C Michael Lane *IMPORTANT: If you, or a representative for you, is not available for the hearing, you will lose the case. If, before the hearing, you give m . a reason for your unavailability and the. Bureau of Hearings and Appeals deems the reason to be acceptable, the hearing will be postponed.. If the Bureau of Hearings and Appeals deems your reason to be unacceptable and you are not available for the hearing, your appeal will be dismissed.. CONTINUED ON REVERSE Please complete and sign the "REPLY TO BUREAU OF HEARINGS AND APPEALS" form below, cut on the dotted line and return as soon as possible in the postage-paid reply envelope to the Bureau of Hearing and Appeals. REPLY TO BUREAU OF HEARINGS AND APPEALS Check all that apply: F-1 I will be available for the hearing on March 14, 2012 My correct telephone number at 10:00 a.m. with ALJ C Michael Lane I need an interpreter. Language needed: 1 will NOT be available for the hearing because: I wish to withdraw my appeal at this time (Only the person who filed the appeal or his/her authorized representative can withdraw the appeal). Signature PW 1765A Date I am a person with a disability and I need an accommodation to participate in the hearing. The accommodation I need is: Ruth C. Aubin 210163127-001 PW 1765 - 3103 '0nnr'4oan1n1• BROCHURE: A brochure is included with this notice which provides a summary of the hearing process and information regarding optional hearing methods. If you have any questions regarding the contents of this notice or the brochure, please contact my office at the telephone number in the heading of this letter. The Bureau of Hearings and Appeals complies with the Americans with Disabilities Act. We will provide reasonable accommodations upon request. Please contact my office at the address or telephone number in the heading of this letter if you wish to discuss special accommodations OR you may describe the accommodation on your "Reply to the Bureau of Hearings and Appeals". Sincerely, 7t. Timothy D. Book Site Administrator cc: Cumberland CAO Ivana Grujic WAM Please complete and sign the "REPLY TO BUREAU OF HEARINGS AND APPEALS" form below, out on the dotted line and return as soon as possible in the postage-paid reply envelope to the Bureau of Hearing and Appeals. BUREAU OF HEARING AND APPEALS 2330 VARTAN WAY SECOND FLOOR HARRISBURG PA 17110-9946 PW 17658 PW 1765 -11/01 EXHIBIT'4E" (TO COMPLAINT) SCHUTJER nBOGAR 309 FELLOWSHIP ROAD, SUITE 200 MT. LAUREL, NJ 08054 © 856.533-2461 ® SCHUTJERBOGAR.COM Email: igmjic*schutjerbogar.com Direct Dial: (850 55 MIN February 24, 2012 VIA OVERNIGHT MA.L Michael Bless 22 Summit Place Cedar Hill, TX 75104 Re: Ruth Aubin •- Medicaid Benefits Dear Mr. Bless: As you are aware, our firm represents Church of God Home, Inc. ("Church of God") in relation to its Medicaid eligibility and reimbursement needs. We have been asked by Church of God to assist in securing Medicaid benefits for your mother, Ms. Ruth Aubin ("Ms. Aubin.") By way of this letter, I am seeking your compliance, as the agent for Ms. Aubin, with the Medicaid regulations governing eligibility for Medicaid benefits. As you know, an application for Medicaid was filed on Ms. Aubin's behalf in August 2011 with the Cumberland County Assistance Office of the state of Pennsylvania ("CAO"). In processing your mother application, we have learned that Ms. Aubin's assets exceed the resource limit established by the state Medicaid regulations governing eligibility for Medicaid benefits. Specifically, as of September 24, 2011, Ms. Aubin had $3,299.00 in her Member's 1St Bank account no. 50026 and $4,835.00 in her Member's 1St Bank account no. 413920. These resources exceed the resource limit established by the state Medicaid regulations and will result in a denial of your mother's application for Medicaid benefits unless immediate action is taken. Bless, Michael February 24, 2012 Page 2 As a result, a spend-down of Ms. Aubin's funds in accordance with the state Medicaid regulations, i.e., payment of your mother's medical expenses, is necessary in order to qualify Ms. Aubin for Medicaid benefits. It is imperative that these resources are spent-down immediately to prevent the loss of benefits. Accordingly, please promptly spend-down Ms. Aubin's resources in accordance with the Medicaid eligibility guidelines to bring her within the resource-limit set forth by the state Medicaid regulations and provide proof of the same in the form of copies of checks, bank statements, withdrawal receipts, or other written confirmation showing that his resources have been spent down. In order to expedite this process, kindly fax all copies directly to my attention at (856) 533- 2461. Again, it is crucial that this be completed as soon as possible. If I do not receive any documents or hear 'from you by Wednesday, March 7, 2012, I will assume you will not be cooperative and we will proceed accordingly. We appreciate your cooperation and prompt attention to this matter. Sincerely, SCHUTJER BOGAR Ivana Grujic, Esq, UPS: Tracking Information Proof of Delivery S Close Window . Dear Customer, This notice serves as proof of delivery for the shipment listed below. Tracking Number: 1ZY99V530195567096 Reference Number(s): CGH-038 Service: UPS Next Day AirO Shipped/Billed On: 02/24/2012 Delivered On: 02/27/2012 10:15 A.M. Delivered To: 22 SUMMIT PL CEDAR HILL, TX, US 75104 Left At: Other - released Thank you for giving us this opport unity to serve you. Sincerely, UPS Tracking results provided by UPS: 03/05/2012 11:21 A.M. ET Print This Page Close Window Patre I of 1 https://wwwapps.ups. com/WebTracking/processPOD?IineData--Mesquite%5 EF S%5EUnite... 3/5/2012 EXHIBIT "F " (TO COMPLAINT) RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 Statement Date Due Date 12/31/2011 Upon Receipt 802839 AMOUNT PAID $ RUTH C AUBIN c/o MICHAEL BLESS 22 SUMMITT PLACE CEDAR HILL, TX 75104 Comments Please make check payable to CHURCH OF GOD HOME, INC Remit To: CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 Please detach and return this portion with your remittance to the address above. $0.00 $(88.19) $0.00 $140.27 $30,248.91 $30,300.99 ?i- ? v y.s rf Balance Forward $30,389.18 $30,389.18 08117/11 - 08/17/11 Pharmacy OTC (1) $15.07 $(15.07) $30,374.11 08/17111-08/17/11 Pharmacy Free Care (1) $57.00 $(57.00) $30,317.11 10/27/11 -10/27/11 Pharmacy OTC (1) $16.12 $(16.12) $30,300.99 TOTAL BALANCE DUE: $30,300.99 ACCOUNT NUMBER FACILITY NAME RESIDENT NAME ACCOUNT NUMBER CHURCH OF GOD HOME, INC RUTH C AUBIN 802839 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Emergency Petition for Preliminary Injunction will be forwarded to a local process server to be served simultaneously with the Complaint and Brief in Support of Emergency Petition for Preliminary Injunction at the following addresses: Ruth Aubin c/o Country Meadows of West Shore 4837 East Trindle Road Mechanicsburg, Pennsylvania 17050 Michael Bless 22 Summit Place Cedar Hill, Texas 75104 Dated: U °2 By: J#e14e Valore, Paralegal rl) IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff/Petitioner, V. RUTH AUBIN, individually and by and through her Agent, MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, Defendants/Respondents. PRELIMINARY ORDER AND NOW, this 13 , day of Docket No. ` d (o CIVIL ACTION - EQUITY 2012, a hearing in the above-captioned matter on Petitioner's Emergency Petition for Preliminary Injunction is scheduled for the .?3 day of , 2012, at / 30 a.m./p.m. in Courtroom No. in the Cumberland County Courthouse, Carlisle, Pennsylvania. M Ic6e! [Nt-,55 '? Jpq f e 0a lo 1,.e ?u4 4u?;,, 4 ACS iKa.l-ed BY THE COURT: J. C-7 r_41 "VI rnw ? ?? co . -r ORIGINAL IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., Plaintiff/Petitioner, V. RUTH AUBIN, individually and by and through her Agent, MICHAEL BLESS, individually and as Agent through a Power of Attorney for RUTH AUBIN, Defendants/Respondents. I' T,HONOTAF' MAR 20 PM 2: 18 QVBERLAND COUNT' `E CIVIL ACTION - EQUIT , PENNSYLVANIA DOCKET NO.: 12-1506 PRAECIPE TO WITHDRAW, DISCONTINUE AND END AND NOW, this 19th day of March 2012, Plaintiff, Church of God Home, Inc., by and through its attorneys, SCHUTJER BOGAR, herein withdraws its Complaint and Emergency Petition for Preliminary Injunction against Defendants Ruth Aubin and Michael Bless, without prejudice. As the above-referenced Emergency Petition for Preliminary Injunction will be withdrawn, the hearing scheduled for March 23, 2012 at 1:30 p.m. in front of the Honorable Judge Albert H. Masland is no longer necessary. Respectfully sub fitted, SCHUTJER B Dated: ' Ot • L'Z/ By: Kirk S. Soh6nage, Esq. PA Attorney I.D. No.: 77851 1426 N. 3rd Street, Suite 200 Harrisburg, PA 17102 Phone No.: (717) 909-8160 Fax No.: (717) 909-5925 Ivana Grujic, Esq. PA Attorney I.D. No.: 311922 309 Fellowship Road, Suite 200 Mt. Laurel, NJ 08054 Phone No: (856) 533-2464 Fax No.: (856) 533-2461 ORIGINAL Attorneys for Plaintiff/Petitioner .4 ` CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Withdraw, Discontinue and End was served via first-class, United States mail, postage prepaid, upon the following: Ruth Aubin c/o Country Meadows of West Shore 4837 East Trindle Road Mechanicsburg, Pennsylvania 17050 Michael Bless 22 Summit Place Cedar Hill, Texas 75104 Dated: 3 ?q I M By: Valore, Paralegal