Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
12-3587
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., PLAINTIFF, vs. JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, i? - 358 eivi (etA CIVIL ACTION- EQUITY DOCKET NO. DEFENDANTS. NOTICE TO DEFEND Pursuant to Pa. R.C.P. 1018.1 Y'O?LJ 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 'xitlr the covet your defenses or objections to the claims set forth against you. You are warned chat if you Jail to do so the case may proceed without you and a judgment may be entered against Vou by the court without further- notice for any money claimed in the complaint or tier any other claim or reliefrequested by the Church of God. You may lose money or property or other rights important to you. YOIJ SHOULD TAKE "THIS PAPER TO YOUR LAWYER ATONCL. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. HIFIR OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A AWYER. 'I- YOU CANNOT AFFORD TO HIRE A LAWYER, THEIR OFFICE MAY BE ABLE 10 PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER I.EGAI. SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FFF Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 1701; (717) 249-3166 -103.')5 Pty AT7y (a q33 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA. CHURCH OF GOD HOME, INC., PLAINTIFF, CIVIL ACTION- EQUITY VS, DOCKET NO.: ,JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, DEFENDANTS. AVISO PARA DEFENDER Conforme a Pa. R.C.P. Num 1018.1 U STI= D HA SIDO DEMANDADO/A EN CORTE. Si Listed d.esea defenderse de las demandas que se presentan mas adelante en ]as siguientes paginas, debe tomar accion dentro de los proximos veiente (20) Bias despues de la notificacion de esta Dema.nda 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 do que si usted fala de tomar accion Como se describe anteriormente, e; caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclarnacion o remedio solicitado por el demandante puede ser dictado en contra suya por ]a Corte sin mas aviso adicional. Usted pued perder dinero o propiedad a otros derechos importantes oara usted. I S`],ED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIAT.?MENTE. SI USTED NO TIENE UN ABOGADO, LLAMI O VAYA A LA SIGIJIENTF OFICINA. ESTA OFICINA PUEDE PROVEFRLE INFORMACION A CERCA DE CONIC, C'ONSEGUIR UN ABOGADO. Si USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLh. QUE ESTA OFICINA L,E PUEDA PROVEER INFORMACION SOBRE AGENCL\S QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHt1RCH OF GOD HOME, INC., PLAINTIFF, JEAN HOC'KENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, DEFF,NDANTS. CIVIL ACTION- EOUITY DOCKET NO.: 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 Jean Hockenberry, by nd through her Agent, Barbara Pugh, and Barbara Pugh, individually (collectively "Defendants") and in support thereof avers as follows: I Church of God is a corporation created and existing under the laws of the ?,;'ommonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street, ?'arlisle. Pennsylvania 17013. Defendant Hockenberry ("Defendant Hockenberry") is an 81 year-old adult .ndividual wlio is a current resident of Church of God's skilled nursing facility located at 801 Xorth I lanover Street. Carlisle, Pennsylvania 17013. Defendant Barbara Pugh ("Defendant Pugh") is an adult individual. who upon information and belief, currently resides at 5470 Union Deposit Road, Harrisburg, Pcnnsylvama 71 1 1 and is the daughter and attomey-in-fact for Defendant Hockeriberry. A true and correct ,„opy of the )ecember 8, 2005 Power of Attorney document is attached hereto as 1-xhibit "A" and incorporated by reference. 4 F;xcept for periods of hospitalization and short stays at home. Defendant flockenberry has been a resident of Church of God's skilled nursing facility since approximately March 30. 2010. At the time of Defendant Hockenberry's admission to Church of God's skilled nursing tacility_ and at all times relevant hereto, Defendant Pugh was operating as Responsible Party and attornev-in-fact for her mother, Defendant Hoekenberrv. h On or about March 30, 2010, Church of God and Defendant Pugh entered into a ,,kritten Nursing Care Admission Contract ("Agreement"), pursuant to which Church of God aw,rccd to to wlde Defendant Hockcnberry with skilled nursing services in exchange for, inter ?rhu, Defendant Pugh's promise to pay a specific monetary fee from Defendant Hockenberry's resources and promise to "complete the application and enrollment process for Medical \ssistance benefits . . in a timely manner." See Paragraph 2 on page 9 of Agreement. A true and correcr: copy of the Agreement is attached hereto as Exhibit "B`' and incorporated by reference The Agreement also assigned to Church of God Defendant Hockenberry's right to apply for and obtain Medical Assistance benefits ("Assignment"). See Fxhibit B.. Paragraph 14 ?.n page ? Specifically, the Assignment provides that "The Resident irrevocably authorizes the Facility to make claims and to take all such other actions as maybe necessary for the. Facility's Viceipt of third-party payments. To the fullest extent permitted by law, the Resident hereby =assigns noti?,; or hereafter payable to the extent of all charges due to the endorse and turn over to The 1,'acilit?\ any payments received from third-parties to the extent necessary to satisfy the .'harges under the Agreement." 8 After Defendant Hockenberry became a resident of Church of God's skilled nursing facility. her bills for the necessary skilled nursing services provided by Church of God ??,ent unpaid. 9 As a result, an application for Medical Assistance benefits was filed on Defendant Hockenberry's behalf with the Huntingdon County Assistance office (-(-',NO") on or about April !.??. Said application is currently pending with the CAO. However, the CAO will not ._?pprovc said application unless and until Defendant Pugh provides the CAC) with the personal ,?nd financial verification necessary to determine Defendant Hockenberry's eligibility for Medical ;assistance benefits. l Unless Defendant Pugh is immediately compelled to produce thc° requested ,verification information and documentation required by the CAO and otherwise take the actions necessary to qualify her mother for Medical Assistance benefits. Defendant Hockenberry's ?pplieation will be denied and months of retroactive Medical Assistance benefits will be lost for Defendant Hockenberry. in accordance with the Agreement, Church of God has provided room, board and I;kilied nursing care services to Defendant Hockenberry and continues to do so, However, in breach of the Agreement, Defendant Pugh has refused ?o cooperate with Church of God's efforts to qualify Defendant Hockenberry for Medical Assistance benefits. X 41. As a result of Defendant Pugh's failure andtor refusal to cooperate with the Medical ?1ss?stancc application and appeals process, an outstanding balance of 1,orty-Three "housand. `t'hree Hundred Twenty and 39/100 ($43,320.39) Doltars, plus interest, costs, and. attorneys l=ees. remains due and owing to Church of God for the cost of Defendant Hockenberry 's skilled nursing care since her admission to Church of God.' A true and correct dopy of the Invoice is attached hereto as Exhibit "C" and are incorporated by reference COUNTI BREACH OF CONTRACT - SPECIFIC PERFORMANCE PLAINTIFF v. DEFENDANTS 1 _ The allegations contained in Paragraphs 1-14 are herebv incorporated by reference as ,f fully set forth herein. lo Pursuant to the Agreement entered into with Church of God. Defendant Pugh agreed. inh°y cilia, to cooperate fully with the Medical Assistance application and appeals arocess. See Exhibit "B." 1 Church of God has provided, and contint.res to provide, Defendant I Iockenberrv ?.vith skilled nursing care services pursuant to the terms of the Agreement. l ° . However, in breach of the Agreement, Defendant Pugh has failed to timely :_lt.ralily Defendant Hockenberry for Medical Assistance benefits and has refused to cooperate %kith Church of God's efforts to secure Medical Assistance benefits on Defendant. Hockenberry's behalf. I et Specifically, Defendant Pugh has refused to cooperate with Church of God's cfforts to c:ornpletc the pending Medical Assistance benefits application and has refused to provide to the CAO the financial verification necessary to qualify Defendant Ilockenberry for '9edical Assistance benefits. Fhis amount will increase by a minimum of Ten Thousand (510,000.00 Dollars for every month that Defendant Hockenberry continues to receive skilled nursing care from Church of God and fails to secure Medical ?` ssistance benefits to cover the same. 4 20. If Defendant Pugh continues to refuse to cooperate in the Medical Assistance ?-ligibility and appeals process, the pending Medical Assistance benefits application will be denied. Defendant Hockenberry will not be eligible for Medical Assistance benefits. and Church Of :rod will have no way to recoup the outstanding balance due and owing to them for skilled nursing services it has provided and continues to provide to Defendant Hockenberrv, Defendant Pugh's breach of the Agreement with Church of (rod has irreparably harmed an(] continues to cause Church of God irreparable harm. 22 - Only a decree of specific performance will adequately grotect the interests of (Zhurch of God and provide it with the benefits and/or protections promised under the Agreement :tnd AsSlk?I"lment. WHEREFORE, Church of God respectfully requests that this Court enter an Order aeg_?iring the specific performance of Defendants' contractual obligations under the Nursing `_`arc Admission Contact specifically ordering Defendant Pugh's immediate cooperation in the \,ledical Assistance benefits application and appeals process, including, but riot limited to: A. Ordering Defendant Pugh to provide any and all financial records and/or other int«rrnation necessary to qualify Defendant Hockenberry for Medical Assistance benefits within five (5) days of this Order; 11. Ordering Defendant Pugh to take any other action necessary to qualifi Defendant idockenberrv for Medical Assistance benefits within five (5) days oi' writtcri notice by, Church of God or the Huntingdon County Assistance Office, including but not limited to, the proper spend down of any of Defendant Hockenberry's excess assets and/or resources in accordance with applicable Medical Assistance regulations; and 5 .FAny other equitable relief that this Court deems just. Respectfully submitted. SCHUTJER BOGAR Datcd: f i` By: Ivana Grujic, Esq. PA Attorney LD. No.: 31 1922 309 Fellowship Road, Suite 200 Mt. Laurel, NJ 08054 Phone: (856) 533-2464 Fax: (856 533-2461 Kirk Sohonage, Esq. PA Attorney I.D. No.: 77851 1426 N. P Street, Suite 200 Harrisburg, PA 1710?_ Phone: (717) 909-8160 Fax: (71 7 1909-5925 Altorneys.for Church of Clod VERIFICATION 1 b.e indersigned hereby verifies that the statements of fact in the foregoing; Complaint 3. ?.-ue ;Ira correct to the best of my knowledge, information and belief I f.mderstand that any -aloe staternonts therein are subject to the penalties contained in 18 Pa,C.S.A. §X1904 relating to i'n?xvorn falsification to authorities. L)ated: t Sharon Cramer, Representative of Church of Cod Home, Inc. E,XHIBIT "A" (TO COMPLAINT) F. V IIYSI)AT AfflltV3Wj #%rr i.rl l») I.. P04 4R1Gtir1A1 AETAIi.?Eb DY; (A+W af:CES rAaxtAoll 2?zaidai ff ' vVtLLt`Ctl)fi CJ tJ?EA A PRQ M (:ORpW)jON TEN EAST1i*H STPIET POWER OF AT'T'ORNEY CAtI ILIA 17013 (7171 2/3.3341 JEAN E. HOMNHERRY to JOHN C. HOCKENBERRY or BARBARA A. PUGH NOTICE THE PURPOSE OF THIS POWER OFATTORNEYIS TO GIVE ME PERSON YOU - AESIGIYATE(YOUR"AGEN"r)BROADPORERSTORXIM .EYOURPPOPERTY, WRICH MY INCLUDE POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADYANCE NOTICE TO YO U OR APP.ROYAL BY YO U THIS PO*= OFA77ORMYDOMNDTIMPOSIs A DUTY ON YOUR AGENT TO EXERCI EGRAN &POWCRS,$UTWRMP'OWBRSAR.R1?")?MED, YDURAGENT MUST MEDUE CAM TOACT.FOR TOUR BENEP'ITANDINACCOR.DANCE WITH THIS POWER O.FATTORNEY. YOZIRA'GENTMAYAXERCfS.E TNEPOWEM GIMMHERE THR'OUGHOUI`Y4 U.R LIFE TVO, E.YENAFTE'R YOU.85COMEINCAPACITAMI), UNLESS YOU.RXPRESSLY LIMIT THE D URA 71ON OF THESE POW.FRS OR YO U RE POATE THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S" AUTHORITY, YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COU,RTCANTAKE AWAY TURPOWERS OFYOUR AGENTIFITFIND,SYOUR AGENT IS NOT ACTdNG PROPERLY THE POWERS AND DUTIES OFANA GENT UNDER A POWER OFATTORNEY ARE EX LAINED MORE FULLY IN THE PENNSYLYANIA PROBATA ESTATES AND FIDUCIARIES CODE, 20 )PA. C.S.A. 0MPTER 56, IF IMEREISANY7*HING.t$OU7 THIS.FORMTHATYOUDONOT UNDERSTAND, YOUSHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. J HAVE READ OR LTAD ,EXPLAINED TOME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. Date: J,2-. Jean E. Hocke berry 7 _ 7b07 'ON 1, JEAN E. HOCKENBERRY, of 1464 Walnut Bottom Road, Carlisle, PA 17013, hereby revoke any general power of attorney that 1 have heretofore given to any person and do hereby appoint my husband, JOHN C: HOCKENBERRY, of 1464 Walnut Bottom Road, Carlisle, PA 17013, or in the event he is unable or unwilling to so act, then I appoint my daughter, BARBARA A. PUGH, of 5470 Union Deposit Road, Harrisburg, PA.17111, as my agent(s). ("my agent") with full power of substitution, for me and in my name, to transact all my business and w manage all my property and affairs as Imight do ifpersonallypresont, including but not limited to exercising the following powers„ ]Durable Power of Attomey This power of attnrnmey shall not be affected by my subsequent disability or incapacity. All acts done by my agent pursuant to this power during any period of my disability or incapacity shall have the same effect and enure to my benefit and bind me and my succmors in interest as if I were -- competent and not disabled, Powers of Agent I hereby empower my agent to do any or all of the following, cash of which is fully defined and explained in Section 5603 of the Petw.sylvania Probate, Estates and Fiduciaries Code, 20 Pa. C.S.A. § 5603,. to include, without limitation, all amplif cation of aaCh powers as specified therein. To make gifts onmybehalf which are limited to tho class ofpersons consisting sot oly of my ,spouse, my issue, and my agent if he or she is a member of such class, or any of them. During each calendar year, the gifts made to any permissible donee, pursuant to such power, shall have an aggregate value not in excess of; and shall be made in such manner ea to qualify, in their entirety, for the annual exclusion from the federal gift tart permitted f'ot myself, and if applicable, my spouse. In addition to tho gifts authoriied above, a gift made pursuant to such power may be for the tuition or medical care of any pormisstble donee to the extent that the gift is excluded fromi the federal giit,tax as a qualified transfer. My agent may consent, pursuant to the. internal Revenue Code, to the splitting of gilts made by my spouse to my issue or a spouse of my issue in any amount and to the splitting of gifts made by my spouse to any othcrpersonin amounts notexeeeding the.aggegate anima! gift tax exclusion for both myself and my spouse under the Internal Revenge Code. i. To create a trust for my benefit. To alter, amend or revoke and to make additions to an existing trust for my benefit, 4 To claim an elective oharo of the estate of my deceased spouse. To disclaim any interest in property. 6, To renounce fiduciary positions. -2- 'tiQl' 'oN "iu, ?I n , ,a 7. To withdraw and receive theincome or corpus of a trust. 6. To authorize my admission to a medical, nursing, residential or similar facility and to enter into agreements foamy care. [See Exhibit "A" attached hereto.] 9. To authorize medical and surgical prooedures. (Sec Exhibit "A" attached hereto.) 10. To engage irt. real property.ft=aotions. 11. To engage in tangible personal property transactions. 12. To engage in stock, bond and other securities transactions, 13. To engage in commodity and option transactions. 14. To engage in banking and financial transactions. 15. To borrow money. 16. To enter safe deposit boxes. 1 To angagc in insufancc transactions. 19. To engage in retirement plan transactions, including to designate one or more beneficiaries or contingent beneficiaries for anybenefits under such plan on account of my death said to change any such prior designation of beneficiary made by me or by my agent; provided, howovcr, my agent shall have no power to designate himself/liorsclf as a beneficiary or contingent beneficiary to receive a greater share of any such bCtlc iU than helshcwould have otherwise received unless such change is consented to by all other beneficiaries who would have received the benefits but for the proposed change. 19. To handle intea:osts in estates and trusts. 20. To pursue claims and litigation. 21. To receive govnment benefits. 22. To,pursue tax nutters. 23. To make an anatomical gift of all or part of my body. 24. To do all other things which my agm shall deem necessary and proper in order to cant' out the foregoing powers which shall be construed as broadly as possible. CNH1 Mq IIIWVa uulti'i; f.?r7 r Reliance on power Ibis power may be accepted and relied upon by anyone to whom it is presented until such person either receives written notice of revocation by me or a guardian or similar fiduciary of my estate or has actual knowledge of my death. I hereby authorize and empower any successor agent to cellify to the death, inability or unavailability of any predecessor agent to function hereunder, and I hold harmless anyone who relies on. such certification. Hold Harmless All actions of my agent shall bind me and my heirs, distributecs, legal representatives, successors and assigns, and for the pu*osc of inducing anyone to act in accordance with the powers I have granted herein, I hereby represent, warrant and agree that if this power of attorney is terrninated or amended for anyroason, I and my heirs, distributees, legal representatives, successors and ,assigns will hold such party or panics harmless from any loss suffered oz liability incurred by such party or parties while acting in accordance with this power prior to that party's receipt of written notice of any such w7nination or amendment Pennsylvaoin Lave Goveras (Questions pertaining to the. v8lidity, construction and powers created under this instrument shall be determined in accordance with the laws of the Commonwealth of Pennsylvania. Signed this clay of WITNESS: Jean E, Hookenberry COMMONWEALTH OF PENNSYLVANIA ) SS. COUNTY CIF C TMB$RL OTI) ) On this, the X _ day of c'e?,.I?ec ? before me, the undersigned ofTicer, personally appeared lean E. Hockenberry, Principal, the person whose name is subscribed to the within instrument, and acknowledged that she executed the same for the purposes therein contained. IN WITNESS WHEJU!0F, I hereunto set my hand an44 tcial seal. ! (SEAL) Notary Public NOTARIAL SEAL VIC1ORIA L. OTIO N07ARY PUBLIC CARLISLr BORO. CUMBERLAND COUICY -4 t?Y o1.3!,l?SS?OtI E}_?,1RES DEC- 06 - .? i'b07 'ou Q11N1'4tPIUi i'tnuu i „? r , i d,j/.j2 / Lbt 17 15: ny 717-21 .858 MARTSON LAW PAGE 02/D3 FF j 'DECLARATION I; Jean E. Hockenberry, being of sound, mind, willfully and voluntarily make this declaration to be followed if I become incompetent, This declaration reflects my fi.rza and settled commitment to refuse life-austaining treatment under the circum- stances indicated) below. I direct my' attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanant unconsciousness. 1: direct theft treatment be limited to measures to keep met confortabae and to relieve pain, including any pain that might occur, by withhold,t.ng or withdrawing life-sustaining treatment. In additioil, if i am in the condition described above, i feel especially strong about fhe following forms of treatment: X ( ) do (>4 do not want eardiae resuscitation, i ( ) do (54 do not want mechanical respiration. z ( ) do (A do not want tube feeding or any other artifi- cial or invasive form of nutrition (food) or hydration (wager). do d¢ not want blood or blood products. do (x) do not want any form of surgery or invasive diagnostic teats, X do ('A do not want kidney dialysis. D-I do +9o not want antibiotics?!9 -*-L z realize that if I do not specifically indicate my prefer- ence regarding any, of the forms of treatment listed above, I may receive that forte of treatment. u?,?irc.oi.u la:u? ?lt-:t ltf?41 MAR79ON LAW PAGE 03/03 Other instructipns: I (pj do ( ) do not went to designate another person as my surrogate to make medical treatment decisions for me if I should be innompetent and in a terminal condition or in a state of permanent vnconsciousness. Name and address of .surrogate (it appl i cable) : __C i L4 Liu Name and address of substitute surrogate (if Surrogate designated above is unable to serve): i=?t?l1.?-a t.?.-1`?• 44 Z made this declaration on the /!2 day of ,a icf i aL ooZ 'R c"', 4/ , f J?(?e Ip '-dean E. 1464 Walnut,8ottom Road Carlisle, PA 1701 The declarant or the person on behalf of and at the direc- tion of the declarant knowingly and voluntarily signed this writing by signature of mark in my presence. Address ?.1. j- ;..1 MASS: 7-2f )A t-?Rt?trat l/? l701.1 + - e F'.XHIBIT "B" (TO COMPLAINT) II II 1I ¦I Church of God Home, Inc. 801 N. Hanover Street • Carlisle, PA 17013 P: (717) 249-5322 - F: (717) 249-8622 Revised VI2,1109 --J 42? i CHURCH OF GOD HOME 'Commitred to Coring Dear Friend: I Admission into a health care facility is a learning 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 dome 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. 3n sharing these values and standards of the Church of God dome, 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 PresidentlCEO a ;MIL M Table of Contents .: i® 1 1 Welcome Letter ........................ ........................ ._..... .... ....... ................ ........ ........... .........., 2 2 Statement of Vision and M ssion ........................................................... ....... ............ ...... . ..... 4 3 Ambulance- ............................................................ ............,...,.. .., ., 4 4 Chart of Costs.. ................................................_....................................... __ .............. .... 5-7 5 Dietary Services.. -, ............. ................ ............ ............................ --- ............ .... ......... ... 7-8 6 DVD "A Time of Transition"..._ ........................................................................................ ...... 8 .' Guest Room ....... ................ .................................................. ........... ...._........... ....... ..... ... _. 8 8 Lehigh Valley Respiratory Care - Lancaster ................................................................... ..... 9 9. Medicaid (Medical Assistance) ....................................................................................... .. 9-10 10, Medicaid (Medical Assistance) Residents ...................................................................... 1 . 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. Saecialiized Services ......... ........ .................. .......................... ................. ........ ............ ..,.. ,.....17 1", Transportation ............................................................................................ .............. .... 17 18. Understanding Restraint Use .............................................................................................. ......18 19 Advance Directive Policy ................................................................................................ ...... ? 9 20. Complaint Procedure ...................................................................................................... ..... 20 21 Delegation of Responsibility Form .................................................................................... ......?1 22. Legal Rights Compliance ........................................... ........................... 2 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. Pnvate Room Policy / Nursing ............ ....... ............... ......... ................. ...... ............. ..... .. ...38 30•. Therapy ...... ........... ......................... ................ ............. ........................ ........... ............. .... ..39 3'; Vaccinations ........ ............ .................,.. 40-45 2, Valuables ...................................................................................................................... ......16 31-' Admission and Care Agreement .................................................................................... 47-55 a. Security Deposit .................................... ...... ....... ...................................... ............ ...,. ....4i7 b. Readmission - Bed Hold Polio 34. Resident / Family Guide to Inquiries and Information ...................................................... 53-:34 35, "Welcome" (Telephone/Extension) ............ .... .......... _...... ............ ......... _.......... ... ..5-5 36 Checklis', ........... .. )6 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 cent ter are available to all persons and visitors regardless of their race, color, national origin. age, ancestry, sex, handicap, disability or religious creed. All aersons 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, cr religious creed. Ambulance Arnbulance enrollment is recommended but is not handled by the facility. It you desire enrollment, please contact ,l em !ndece-?dently. Chart of Costs Nursing Care Room Rates Faith Wing and Love Wing Semi-Private $241.00 per day Private $296.00 per day Persona{ Care Room Rates Effective January 1, 2010 Hope Wing and Peace Wing Semi-Private $107.00 per day (Rm401-411) Private $115.00 per day (Rm301) $126.00 per day (Rm303-313) $134.00 per day (Rm400) Creekside ,apartments Studio One Bedroom One Bedroom, Creek view One person $149.00 per day $169.00 per day $174.00 per day Two persons $251.00 per day $277.00 per day $323.00 per day Note: There will be a security deposit charged based on a 31-day month at the per diem rate for roomilevel of care. In the event of a Level of Care change to a higher level the residentiresponsible party will be billed the difference between the security deposits. There are no additional charges while receiving Ixnefits 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 Fee One Person Two Persons A $914 $1,227 B $843 $1,136 C $843 $1,136 C $828 $1,126 E $828 $1,126 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 Living Rates Creekside Apartments A?artmert Monthly Fee One person Two Persons l-11 cienc:y $1,318 $1,803 ire Bedreocti $1,667 $2,313 5 Chart of Costs (continued) Bed Hold (during hospitalization or LOA) Cable Television (Nursing and Personal Care) Cable Television (Independent Living) Cable Intern4 Cable Modem Clothing Name Labels Guest Room (maximum stay of 5 nights) Incontinence Supplies iners 3riefs ! Pull-ups Miscellaneous supplies Laundry Service (personal clothing) Medication (self administered medication) Photocopies (copies of records) Therapy (physical, occupational, speech) Private Telephone Purchase Telephone Set Monthly Line Fee Hook-up, Activation, One Outlet (one time charge) Dietary Services (guest meals, includes tax) Breakfast Dinner Supper Sundays and Holidays Nutritional Supplies Extra Dietary Service Medications, Medical and adaptive equipment, Alarm pads, special requests, etc. Transportation Services Oxygen Concentrator Usage Portable Oxygen Usage CPAP, BIPAP and Supplies Per Diem rate Irfcluded $22-00 /month $20.001month $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 $33.75/month $15.00/month $1.281pg(1-20) $0.951pg(21-60) $0.32/pg(61 +) Actual cost unless covered under Medicare or co-payment by secondary insurance At own expense $30.60/month No Charge $5.00 $7.65 $6.30 $7.65 25% above cost Contact your social worker At own expense unless covered by your insurance or covered by medical assistance benefits 0-10 Miles (round trip). _.122.00 11-50 Miles (round trip).. $44.00 51-76 Miles (round trip)... $75.00 Escorts,...... _ .$10.00mour $3.00/day, unless ccvered under Medicare $12.00/cylinder, unless covered under Medicare Actual cost 6 Chart of Costs (continued) Hair Care Frost $48.00 Cut, Men $11.25 Cut, wash, blow dry $26.00 Cut, ;Nomen $12.25 Hot wax $7.15 Men's cut and moustache trim $12.55 Oil treatment, shampoo, set $24.50 Permanents $54.05 Permanents in bed $59.50 Wash, no blow dry $8.45 Men's/Women's cut-wash in bed $28.35 Color rinse $1.05 Dietary Services Cut, wash and set $25.00 Re-comb $8.45 Re-comb and curling iron $11.75 Tint $28.60 Wash and set $12.75 Wash, blow dry $13.80 Men's/Women's wash in bed $16.10 Wash, style, blow-dry in bed $29.40 Men's cut - wash $19.65 Mustache trim 51.30 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 consut,s with residents and families. Our three-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 flue 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 understandinq and cooperation. Families are encouraged to participate in special meal events throughout the year, such as our Parents t)ay and cliday 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 S IZE ----- - - --- SERVES CAKES: COST wdTAX 9" Round 2-1 a-y-e r -s 16 $15.00 _ '/< Sheet - '10"x14" 16 $15.00_ - '/2 Sheet -1 `x 17" 30 $20.00 Full 60 $30.00 ICE CREAM.-, Hand dipped - dishes _ $1.00 I -Hand di fed -_ 3 gal. container ---- - ---$17.50 Dixie Cups - (24) 4oz. containers Vanilla / Chocolate $10.00 j GUEST MEALS: r Breakfast $5.00 Dinner $7.65 ) Supper $6.30 $7 65 Sunda and Holiday . MISCELLANEOUS: _ 3 lb Chi P $9 75 ps - s otatoes . Pretzels - :3 Ib. $7.55 ! Punch -1 gal. - $4.00 ' Lemonade $4.00 Iced Tea - 1 gal. $4.00 - -- I doz. Any Kind Cookies - -- ---- -$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. ?' s` ? initials} Guest Room There s a cost per night with a maximum stay of five nights. A second person in the room is an additio nal charge per night. No young children please. Your friend or relative will be billed for their stay. Reserva tion ran be made through the Residential Housing Administrator (717) 249-5322 extension 3085. 8 LEHIGH VALLEY RESPIRATORY CARE - LANCASTER 1176 Enterprise Court - East Petersburg, PA 17520 (1717) 569-4667, 1-800-952-84;52, Fax (7'17) 569-5555 Lehigh Valley Respiratory Care - Lancaster is an independent Home Medical Equipment Company providing respiratory services to Long Term Care Facilities. We are accredited by the Joint Commission of Accreditation of Healthcare Organizations to perform Clinical Respiratory Services. Lehigh Valley Respiratory Care - Lancaster provides Church of God Home residents with oxygen and respiratory supplies. The Church of God Home will contact Lehigh Valley Respiratory Care - Lancaster for these services when initially needed. Personal Care Residents: • Lehigh Valley Respiratory Care -- Lancaster will then contact the Resident/Responsible Party to schedule the arrangements and discuss their billing procedures. • Oxygen 1 Respiratory Supplies may be covered under Medicare Part B as long as the qualifying criteria have been met. • Lehigh Valley Respiratory Care - Lancaster will contract with the Resident/Responsible Party on an individual basis and will bill Medicare Part B directly. 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 administrative and operating procedures. Medicaid's major distinction from Medicare is a Pffn of financial aide Medicare is a type of healthcare insurance. When resident resources are re d to $15,000.00, the facility Business Office should be l6e notified immediately. The following instructs will apply: j' 1. Resident/Responsible party will be responsible for a burial reserve set up at a bank or funeral horne with amount equalizing enough for burial. The amount set aside should include amount of life irsurance 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, is the legal responsibility of the POAIRepresentative 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 POA1Representative Payee does not follow through in a timely manner', that the Church of God Home, Inc. reserves the right to file the apc iication on the resident's behalf. 3. 1 he 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 i 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 res dentlresponsible party regarding available options. 4 To appeal a decision regarding a Medicaid Assessment, contact: The Pennsylvania Department of Public Welfare Centre County Assistance Office (Cumberland County Long Term Care Unit) 2580 Park Center Blvd State College, Pennsylvania 16801 P: (814) 863-6571, 800-355--6024 Fax: (814) 689-1356 To appeal a decision regarding a level of care assessment, contact: The Cumberland County Office of Aging Long Term Care Program Human Service Building 16 West High Street 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 aersonal 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 MUtine 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. 6 Upon transfer or discharge for hospitalization of a resident receiving medical assistance benefits, the facility will hold a bad. 10 M 42b? 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 REQUIRED by Pennsylvania State Regulations. 2. Medical Insurance Premiums will be deducted from the Resident's monthly income and the balance of the income less a 5.00 allowance will be applied to room and board, 3 Prescription drugs, physician visits, dental services, and eye examinations are covered by Medicaid, but only with participating dentists and ophthalmologists. Potential charges will 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 + Perscnal 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 hook-up, 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 yea ;Date; (Res den; Resporsable Party' " i ,r R(s de ; ^lr,rn A? '7 , ±Fac: ` ty " Medicaid (Medical Assistance) Resident's Checklist CENTRE COUNTY ASSISTANCE OFFICE (Cumberland County Long Term Care Unit) 2580 Park Centre Blvd State College, Pennsylvania 16801 'Telephone: 1-800-355-6024 or (814) 863-6571 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 f 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 (RedMhitelBlue 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 --- 5.1-ong 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 nterest income 10 -'rovide current statements for ALL bank accounts, stocks, bonds, trusts, IRAs, Keoghts, and Annuities - must provide values of 1'. 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 _s 1:! Files. vehicle registration, and insurance for all vehicles owned, including boats, motorcycles, and trailers 12 3 __ td Cirrent cash value of ail 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 vatiue from the insurance company. Deed to burial plot(s) or statement from cemetery i"opy of Burial Trust / Reserve (including Statement of irrevocability) 0 )eed 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 8 Title to mobile home and it's current market value - if transferred or sold within the last 5 years, provide a impy of the new deed and the settlement sheet for all sold property Any unpaid medical bills you wish to see if Medical Assistance would cover 2- teen? I mortgage payment proof Utility Bills A. Electric B Gay G. Oil Heat E Telephone F Water G Sewer H Trash 22 income ax Returns - for the past 5 years, provide all schedules and 1099 Forms 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 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, ar.d V 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. 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 sen/ices. 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 II if ycu 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 bene'?it 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 11 through the Will day, as long as you continue to meet the criteria to, daily Skilled Nursing Care or Rehabilitation Services, hospital insurance pays for all covered services except for $137.50 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 g Regular nursing services Rehabilitation services, such as physical, occupational, and speech therapy A 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 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 nurse, Any extra charges for a private room unless it is determined to be medically necessary k Transportation Name Labels Hair Care Oersonal 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 1-800-633-4227. The Church cf 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-RaylUltrasoundlEKG 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 regior. 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 thy. 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 Pernsylvania. All EKG and cardiology related exams are interpreted locally by Associated Cardiologists, P C, MIX 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 thiE 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 insurana?, and Medical Assistance third. There will be no bill to responsible parties. Fee ?ree to contact Philhaven Hospital at (717) 270-2413 or 1-888-740-821,1 if you need further clarification We at the Church of God Home welcome this new dimensior of expertise to our highly qualified st:Iff 16 Smoking Policy -the Ch. urct, 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. It 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 fe 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 mar ual 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 ccntrol 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 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 • ontractures • Reduced social contact 18 42!bIll, 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 conceming 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. 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. Z Gate; ( esidenUR€:sponsible ?arty ( esid t Name (Facility R `g 19 a 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: Procedure: 1 (Dale) ---- To assure the Home's Mission Statement is being upheld to its highest integrity. 1. Any wdtten or oral complaints presented by or on behalf of a Resident to the Church of God Home or DPW 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 PCU Administrator 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 andlor designated person. 6. All complaints will be placed in a binder with the findings and plan of correction. The PCU Administrator will maintain the I: 20 4mbl? CHURCH OF GOD HOME "Comrnitted to Caring" DELEGATION OF RESPONSIBILITY FORM As a result of medical and/or pinysical 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. - is medically/physically capable of Y e of silent) understanding Resident's Rights but designates this to: (Dae) ResidenUResponsible Party) AR id t Name / (Facility Representati 21 J i 42 CHURCH OF GOD HOME Committed to Caring' I ¦ 0? LEGAL RIGHTS COMPLIANCE RESIDENTS AWARENESS COMMONWEALTH INFORMATION CENTER 402A Finance Building Harrisburg, PA 17120 Telephone: 'I-800-932-0784 PENNSYLVANIA DEPARTMENT OF HEALTH DIVISION OF NURISNG 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 16 West High Street Carlisle, Pe\ 17013 Telephone 717-240-6110 1 ,Date', PENNSYLVANIA DEPARTMENT OF AGING 555 Walnut Street Harrisburg, P.A 17101 Telephone: 717-783-7247 PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE CENTRE COUNTY ASSISTANCE OFFICE (Cumberland County Long Term Care Unit) 2580 Park Center Blvd State College, PA 16801 Telephone: 814-863-6571 1-800-355-6024 MID PENN LEGAL SERVICES 401 East Louther Street Carlisle, PA 17013 Telephone: 717-243-9400 ? 1- iR idenVResponsible Party) P J 22 m, 424 CHURCH OF GOD HOME 'Cnmmitted in Caring" NON-DISCRIMINATION STATEMENT m accordance with applicable! Federal and State civil right laws and regulatory requirements, you, as a resident of this facility, have the right upon admission: • Tc, be provided services at this facility and to be referred for services at other facilities without re(,Iard 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 Church of God Home, Inc. 801 N. Hanover Street Carlisle, PA 17013 Phone: 717) 249-5322 Department of Health and Human Services Office for Civil Rights 150 S. Independence Mall West Suite 372 Philadelphia, PA 19106-3499 Phone: (215) 8614441 Pennsylvania Human Relations Commission Harrisburg Region Office Riverfront Office Center 1101-1125 South Front Street, 5th Floor Harrisburg, PA 17104-2515 Phone: `7171787-9784 c Uate) 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 23 r i ¦ 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 ¦I Note Regular business hours are 9:00 a.m. to 3:45 p.m., Monday through Friday, except holidays. Deposits The resident or family member t 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 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. 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. ¦ 24 Personal Cash Accounts (cont.) CHURCH OF GOD HOME "Committed to Caring" Authorization to Handle (Personal Funds (Dale) l¦ ¦ Depleted Funds When resident's assets reach $15,000.00, family/responsible party should contact our Business Office immediately. Family member 1 responsible party will have to apply for Medical Assistance. Residents with no family member / responsible party, our Business Office will apply for Medical Assistance. Residents will receive 5.OC1 monthly from their income for personal needs. Other monies may be deposited into each PCA, as the resident or family membelresponsible p S. ( ;e!kenVResponsible Pa (Date) 25 -V =- -- -- - -- -- {FadI4 Representativ ik 42 CHURCH OF GOD HOME "Commined to Caring' Personal Laundry Service This is to advise that the personal laundry will be laundered withi / outside rcle 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 / personal items. Please contact Social Services or Charge Nurse. • Dry ,leaning and Alteration Services are not provided, • No wool items are accepted. (ResidenIlRespcnsible Pa (©a'°) (Re IVarne) (Facility Representa e- 26 Pharmacy Services 28 South 2"3 Street Specialist in 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 tablet/capsule 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. s Medical Records - A medical records staff member maintains and prints monthly charts that are utilized by the caregivers, nursing staff and physicians. s 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' ;harts 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 fost-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. 'Be. at Cortiiiuing 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- alease contact Continuing Care RX with any questions or billing concerns at 1-800-675-2279. 27 Privacy.Vonce 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 %is 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 arc 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 Notice, we will promptly post the revision [insert location, such as on a website]. You also may request and obtain a copy of any new/revised Privacy Notice from the contact person identified on the last page of this notice. Should rot have questions concerning our Privacy Notice, our contact information is listed on the last page of this document. 11. How 1Ne May Use and Disclose Your Protected Health Information 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 same degrix 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: I . 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 aide sltechnicians, 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_ Lse 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 scrOces we provided to you_ 28 rn,a . i'oure rise and Disclosures Related to Health Care Operations We may use or disclose your protected health information for the performance of certain hinctions 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 Benefits and Services We may use or disclose your protected health information for purposes of contacting you to inform you of treatment aiternatives or health-rrlated benefits and services that may be of interest to you, such as a newly released medication or 'reatment that has a direct relationship to a treatment or medical condition. III. Uses and Disclosures Requiring Your Written Authorization 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 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 Authorizationfor 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- 1.xamples of uses or disclosures that would require your written authorization include, but are not limited to, the following: 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_ A request to provide PHI 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 hest 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 fray 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 VI, paragraph 1.) V. Uses and Disclosures of Information That Do Not Require Your Consent or Authorization State and federal laws and regulations in some instances either require or permit us to usc: 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 fallowing: 1 When Required by Law: u e may disclose your protected health information when required by federal, state or local law. Privacy Noticr 29 prrvacy;vouce Abuse, Neglect, or Domestic Violence: !y,s 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: 1"o 'he 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 Rec Cross) to assist in disaster relief efforts. S. Food and Drug Admini.-oration (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 a drug or medical device. t,. For Public Health Activities: #s 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. 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. h To Coroners, Medical Examiners, Funeral Directors, 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 direaor 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, Ftrr Research Purposes: *e 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. f 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 ConfrdenuQlity and Nr.;n-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, fo 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 health x :;afety 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 ham- I l . For Jtudicial or :Administrative Proceedings: We may disclose protected health information about you in the course of a judicial or administrative proceeding, in iccordartce with our legal obligations. 30 s 1 2. 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 by law, 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 :n loci parentis, in accordance with our legal and ethical responsibilities. t,t. 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, ifyour child is legally authorized to obtain services (without separate consent from you), and does not request that you be treated as his or ber personal representative, we may not be required to disclose protected health in formation about your child to you without your child's written authorization. H4. To Personal Representatives: If you are an adult cr 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. 10. 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 ofcarrectional institutions. 17. For Workers' Compensation: We may disclose protected health information abut you for purposes related to workers' compensa*ion, as required and authorized by law. VI_ Your Rights Regarding Your Protected Health Information Yoo 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 . ro Request Restrictions on Uses and Disclosures of Your Protected Health Information: "ou have the right to request that we limit how we use or disclose your protected health information for treatment, payment or health pre 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 gfProterled Health Information form. Our contact information for purposes of making such a request is :fisted on the last page of this document. We are not required to agree to your restriction request. You will be informed if we decline vour request. Ifwe accept your request, we will comply with your request not to release such information unless the information is )ceded to provide emergency care or treatment to you. Arwgcti Notice 31 Privacy N'onc'e '. The Right to Inspect and Copy Your Nealih and Billing Records: 'r'oj 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 Iasi 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 ofthe denial, if any. In the event of a review, we will select a licensed health care professional not involveai 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. i. '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 maintainlretain your protected health information. Your requests must be submitted to us in writing. We wil) respond within sixty (60) days of receiving the written request, unless an extension is necessary, in which case you will he notified, and receive a response to your request within ninety (90) days. If we approve your request, we will make such amendmertts/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; h Your written request does not contain a reason to support your request; The information was not created by us, unless the person or entity that created the informatior is no longer available to make the amendment, d It is not a part of the protected health information kept by us, it is not part of the information which you would he permitted to inspect and copy; and/or 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 amen drnent/coneclxion request should be submitted on our Request for AmendmeneCorrection of Protected Hootth 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. 'fhe 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 yr,ur request as long at it is reasonable for us to do so. You may submit yout 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. Chu contact information is listed on the last page of this document. 5. 'hare (tight 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 11zivc made for the purposes of treatment, payment, or health case operations or information released to you, your . vac. N oax:1 32 'Y r'•Ic, 'h Uz!( ° family or friends for notification purposes, disclosures made for national security purposes or to certain law enforcement officials, incidental disclosures. disc'osures made as part of a limited data set (for use in research, public health, etc.), or any disclosures made pursuant to your autborization. Your request must be submitted to us in writing and must indicate the time period for which you wish the in formation (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 roust 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 w]] 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 Information 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. VI. How to File a Complaint About Our Privacy Practices If you havQ 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 filing a complaint. Ycu 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. i)ivacy No?icc 33 42 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 Fuliq 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 determine these benefits payable for related services. Yes, I have accepted Dr. William Pulig as my podiatry care physician ] No, I decline offered podiatry care physician for my podiatry care ( Date) ;Re denVResponsittle Party; (O?W nt Name) (Facility Represen i ) 35 42b? CHURCH OF GOD HOME Committed to Caring' Privacy Act Statement-healthcare Records This form provides you the advice required by the Privacy Act of 1974. Tnis 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 ReG)rds. 2 Principal purposes for which information is intended to be used T-;e 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 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 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. (we) acknowledge receipt of the Pdvacy Act Statement - Healthcare Records (Date) nsib'e Party A i 4 J? (Fackity Represent 37 42bli, 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 need for an isolation room arises. This room is identified as Room 118 Faith Wing. 2. Any resident using room 118 must agree on admission that they will move out of the room to a semi-private room if the facility needs to use it. 3, When a need for an isolation room 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? 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. 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. t (Date) (R den esponsibie Party, ,f (Facility Represe^t' '38 42? 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 I Responsible Party may contact our Business Office with questions related to therapy billing. The ndersigned heceby cons e is to a prov ion of therapy services for A /144 (the Resident) as ordered by Res' en physician and deemed necessary to attain or aintain the highest practicable physical, mental and chosocial 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. 1(\ 21 ,'Dated (R sidenUResponsible Party'i esiii t Name)° ty, '- V ac [ -,y Rep € Berta' 39 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. Sorr:e 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 n 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 bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, 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 means that you may be able to pass on the flu to someone else before you know you are sick, as well 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: n The "flu shot" - an inactivated vaccine (containing killed 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 1 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER • HEALTHIER- PEOPLE- ;I 40 Key Fads About Seasonal Influenza (Flu) The nasal-spray flu vaccine -a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called IAIV for 'Live Attenuated Influenza Vaccine«). LAIV 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 in`ectior. Flu vaccin°s 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 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 for high risk persons. During flu seasons when vaccine supplies are limited or delayed, the Advisory Committee on Immunization Practices (ACIP) makes recommendations r ardino priority groups for vaccination. People who should get vaccinated each year are: t People at high risk for complications from the flu, including: Children aged 6 months until their 51h birthday, Pregnant women, People 50 years of age and older, I People of any age with certain chronic medical conditions, and People who live in nursing homes and other long-term care fedflies. I 2. 6le?vle 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 5 months of age (these children are too young to be vaccinated), and « Health care workers. 3. Children aged 6 months up to their 191i 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 care 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 i Page 2 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER- HEALTHIER- PEOPLE' a I A 11 41 I 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-Barre syndrome MS) within 6 weeks of getting an influenza vaccine previously. Children less than 6 months of age (influenza vaccine is not approved for use in this age group). People who have a mcderate 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 entire about preventing the flu, see the following- • Kee Facts About Seasonal Flu Vaccine Influenza Antiviral Drugs Good Health Habits for Prevention The clu: A Guide for Parents 'HL?althy` indicates persons who do not have an underlying medical condition that predisposes them to influerza complications. ¦ For more Information, visit www.cdc.govlflu. or call CDC at 800-CDC-INFO (English and Spanish) or 886-232-6348 (TTY). Page 3 of 3 DEPARTMENT of HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL ANn PREVENTION SAFER, HEALTHIER, PEOPL E..' 42 PNEUMOCOCCAL VAC C I N E POLYSACCHARIDE ?4NHAT YOU NEED TO KNOWN; ?u^Y Ha¢itm INmtutbn 9atemeNS ae avtie6k in S".". end atha tenpueges. See uww.imnvnixe.vpheis 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 fart, pneumococcal disease kill:. 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 pneumococcal 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, HiV - cirrhosis infection, or certain types of cancer. - leaks of cerebrospinal fluid Pnetunococcal disease can lead to serious infections of the lungs (pneumonia), the blood (bacteremia), and the covering of the brain (meningitis). About I out of every 20 people who get pneumococcal pneumonia dies from it, as do about 2 people out of 10 who get bacteremia 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 pneumococtal infections more difficult. This makes prevention of the disease through vaccination even more important. Pneumococcai polysaccharide vaccine (PPV) The pneumococcal polysaccharide vaccine (PPV) protects against 23 types of pneumococcaI 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 tvrll 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. Pneurnot:occal Polysaccharide 43 L How many doses of PPV are needed? Usual+.y 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. ?'+, second dose is also recommended for people who: have a damaged spleen or no spleen have sickle-cell disease have HIV infection or AMS have cancer, leukemia, lymphoma, multiple myeloma have kidney failure have nephrotic syndrome have had an organ or bone marrow transplant are taking medication that lowers immunity (such as chemotherapy o., long-term steroids) Chi dren 10 years old and younger may get this second dose 3 years after the first dose. Those older ? han 10 should get it 5 years after the first dose. Other facts about getting the vaccine Otherwise healthy childrer, who often get ear 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 .Dose with lower resistance to infection. But these pfbple should still be vaccinated, because they are more likely to get seriously ill from pneturococcaI disease. Pregnancy: The safety of I'PV for pregnant women has not yet been studied. There is no evidence that the vaccine is harmful to either the mother or the Cents, but pregnant women should consult with their doctor before being vaccinated, Women who are at high risk of pneumococcal disease should be vaccinated before bmomiry; pregnant, if possible. ?l61 What are the risks from PPV? PP1i' 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 raven. 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? J` What should I look for? Severe allergic reaction (hives, difficulty breathing, shock). What should I do? • Call a doctor, or get the person to a doctor right away. • Tell 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 1-900-922-7467 VAERS doer not provide medical advice. C$ How can I learn more? - i • Ask your doctor or muse. They can 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 website at www.cdc.gov/vaccines . i DEPARTMENT OF HEALTH AND HUMAN BERVIOES CENTERS FOR DISEASE CONTROL AND PREVENTION Pneumoeocca7 Vncane Information Statement 44 42b? CHURCH OF GOD HOME 'Committed 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-'talent 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 Td-Valent Influenza vaccine be given annually per facility protocol. No I do not wish to receive the Tri-Valent Influenza at any given time. have received literatuae 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. have received literatu4e pertaining to the benefits of the Pneumococcal Pneumonia Vaccine. it known, please indicate the date when the vaccines listed below were last received Tri-Valent influenza vaccine: Pneumonia Vaccine: Tetanus Vaccine: )IJ Datai J?,RidenVResponsible ,i 14 i h A ild8 t r?m?°Ti?1 a 45 42b? CHURCH OF GOD HOME 'Committed to Carm 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 ($5.00) at any one time in their possession or rooms, and keep no valuables, real or intrinsic, in their rooms. By signing this paper you acknowledge being informed of the Home's recommendations. Some people have wisely substituted zircons for diamonds and kept the settings. It is ]he responsibility of the resident or the responsible party to have 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) ResidenViRespon5ible Party a 4?si,t Name) j {Facility Represen ? 46 CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT THIS AGREEMENT is made on this _ day of 20, by and between the Church of God Home, Inc., called the "Facility," a Pennsylvania n n-proft corporati Iola d at 80 North Hanover Street, Carlisle, umb and County , nnsyl ania, and called "Resident" an call esponsible Party". The Resident and the Responsible Party reaffirm th a 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: 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 medically indicated. e. Activity programs, Spiritual programs, and Social: Services. Z RECURRING CHARGES - In exchange for the above services; the Resident shall pay the following recurring charges: a. For skilled nursing care: $_J j- dO 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 :', No interest will be paid on the security deposit. A security deposit will not be charged to 'residents 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 Assisted Living, the Resident will be bilied the difference between the two Security Deposit rates. c. T he 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) (Jays - Medicaid iii. Thirty (30) days - Personal Cash Account There will be no other refunds, in the absence of an over payment, under this Agreement. 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 cr other service provider is properly licensed or registered under the law, and that all applicable government rules and policies of the Facility are met. In addition tc the Facility's charges, the Resident is responsible to pay all fees and costs for goods or services fumished 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 rate/charge. ADMISSION - The Resident will be admitted, or a bed will be reserved for Resident, beginning on 3 - 3 e) . 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, ever+ if the Resident does not enter the Home for whatever reason, including illness, injury, incapacity or death. 8 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. d, 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. e Pharmacy changes will be billed as a separate part of the Facility's monthly bill, and will require a separate check. 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 k Admission and Care Agreement- continued 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 Resident's bed will be reserved and changes for the reserved bed will continue to accrue unless the Resident or Responsible Party otherwise directs in writing. 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 ieave 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 reservabon 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 wih 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 do not wish to hold a bed in the event of a hospitalization. I understand that by doing / so, the bed may no be available for readmission. ?--To be determined at time of hospitalization. 1. REFUNDS - The security deposit for private pay residents, after deductions for the payment of any outs,?anding 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. 2. 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. t'ie Resident designates someone other than the Facility to manage hislher personal funds, the resident or Responsible Party shall notify the Facility promptly. The Resident is not required to yak any designation, and is responsible for his/her own personal funds un`!ess such designation is 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 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 011 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. 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 bet by the Facility; !i. The Resident's health or condition has improved sufficiently that the Resident no longer needs the sentices provided by the Facility; ii. The safety or health of individuals in the Facility 'is or otherwise would be endangered; iv. The charges cr 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 tip. 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 ?f the Resident has riot 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 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 facility 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 nametag labels are needed for clothing items, please leave them at the nursing stat=. 16. RESPONSIBILITIES OF RESIDENT- The Resident shall comply fully with all govemmental 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. 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 'his .Agreemenr. 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. (?a'e) ?Resi=?lientResponsible Partys 52 RESIDENT I FAMILY GUIDE TO INQUIRI ES AN D INFORMATION u, C ? ` H O h ° i y a O C Cf, E N _ _ ° ?d Inquires CS - d? U t ?[ ? O ?t ? ?_ o ap R o v v ws ?? Q xrn m0 0 ? E a u 0 d 0 2Of 3 0 m o E " Z z0 wm< cn° n 0 g o r > Healthcare ---?- -- Personal Care X ' Admissiors - - - ? -- --- - --- Independent ? - Living j X Admission -? - - -- - ?-- -----_-- - - Billing Question }( ; Medicare I x - ?-- - ?---- - ----- __ Question Applying for - Medicaid _ - - Pharmac Billin ! x - g y -- - - - - ----- ---- -- _--- - -- Laundry Billing X ? ? - Donation Monetarv x - -- Donation Other --- -- -- ? -- - Personal Cash - - -- --- _ _- ------__--+ Account X Questions Personal Cash ?- '---- ?- ---+ ---------.--- ---.-- -- Deposits / X l Withdrawals ? _ Guest Meal __ -- -- ?- -- -- --------- - ----- Reservations ; X j Parly Reserving of Lounge -- x - - - -- ------ -- Family Concerns - - --- ? --- -- --- - _? _ _ l HIPPA Changes x i Coordinate Change -_r- - X ±-- -- in Level of Care 1 x Resident Lost Items ? _ --? -----?------`- - - -- --- X - ---- i Telephone ? --- ----- Cable o X HcK,k-up - -- -- - ------- ---- ---- -- Le -ort Guest Suite 53 RESIDENT t FAMILY GUIDE TO INQUIRIES AND INFORMATION O ? ( i i0 W 'gyp N C :?+ d aV ? j .-. .+ y y to d .°_: nquires - f C3 Q .= 0O C O? v aeq K- d eo ? r+ W C V o ! ?6 Cf eL.1 ? m U L _ ? "d U 1- a a) te a) C ?4 "O tID ._ V r/! 1 'U (D E m C a. C.1 o (D Q . X(0 m0 c.) w0 , OM 2w z0 ° OC=Q Ch fn 7® ---- Change in Laundry + -- i ?-- - _ Service - - I -- --- x Transport -- ------- - Requests x i x Spec.ial Hair Care Requests, Payment Scheduling X ---_ __ ----- --- --_---} --- ---_-J_ - Resident Care i ? X --- -- - Resident Medication ? ! Physician Questions ' I X i ? ---- _ - - }- -- - -------?---- -?---- - Therapy Questions ? Taking Residents -_ i ---i ----- f -----_ __,_.-_ - Out of Facility X Change in POA -- ---- --- -- Contact X Address /Phone ? , Change in POA ---- ---_- -- r--- ----- -- - X --- - -- - _-t- - Health Insurance ! t ! Cards ? X I _ Religious Questions _--_______ --- ----;--------------i-__-_. - Funeral Questions -- i X - I - -----? --- -- - -- a Funeral Procession Service ' X -^--_ - Memorial Services j -- - -?-------- "The Orchards" at X - j - Marsh Run X 54 M,L Facility Mailing Address: 801 North Hanover Street Carlisle, PA. 17013 Facility Main Telephone #: (717) 249-5322 Facility Administrator: .. ..... ............ Susan Bower, NHA ........... .................... ......__....... ........ ....ext. 3086 -- Y Y Y Y li v Y Y Y Y Y Y Y Y Y- Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Activity Dept.: ?....r.........AmyFindon, CTRS ............ ............. .............................ext. 3021 (Director of Activities) Business Office: A / .............. Sharon Cramer (Business Office / Henderson House i...............t?'?.ext. (Sr. Billing AIR Specialist - Personal Cash Accounts) ............ Michele Shughart (Business Office I Henderson House) ...............(ex 3095 (Billing Specialist -- Medical Dance) _ are Plan. ] . Lynne Shellenberger, RN (Mtg. wfin 14 days of Admiss' n ..ext. 3033 (Nursing Assessment Coordinator - RNAC) ?--? Chap ain; ,w._ __. w ? ............. Pastor Bradley Moore............................. ....................... ext. 3022 Dietary ? .... ...... Bradley Weiser ........................................ ... ................ ext. 3022 (Director of Dining Services) Hair Care: ? ..............Joan Ludwig ...................... ................................,,...,....,.., .. ext. 3003 (Director of Hair Care) Medical Appts.: ? .............. Jessica Dietz ........................................ ............ ...... ............ ext. 3961 (Nursing Administrative Assistant) Nursing Dot.: ? ............. Mary Hartman, RN, BSN .......................... _......... .......... ... ext. 3015 (Director of Nursing) ? .............. Faith Long Hall (#103-116) ........, ..........' ,............ ext. 3009 Faith Shod Hal! (#99,100-102, 117-126) ,... . , :.. ex .............Love 1 #201-215 ...................... ext. 3024 ... Love 11 #217-239 ........... . ............................ ext. 3025 ? .............. Chris Ward, LPN....................,................ ......................... ext. 3012 (Person Care Administrator), (Hope, Peace and Creekside Apt.) Pharmacy_ ? ..............Continuing Care RX.... ....... .......... .....,... ._...............1-800-675-2279 Social Services: ....... Efin Naylor, MSW.............................. ,..... (`e . 30$4 (Director of Social Services) ? ..............Ellen Myers, BSW...................................... ...,......... ........... .. ext. 3023 (Social Worker) b ) Therapy Dept.: Genesis Rehabilitation Services... ext. 3017 Volunteer Office: ? .............Linda Waggoner...,.................................................. ext. 3028 (Director of Valunteers) Physician Telephone -- 55 RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 717-249-5322 $8,122.00 $10,172.27 $1,400,51 AMOUNT PAID $ .39 Statement Date Due Date 04/30/2012 Upon Receipt 803010 Please make check payable to CHURCH OF GOD HOME, INC JEAN E HOCKENBERRY c/o BARBARA PUGH 5470 UNION DEPOSIT ROAD HARRISBURG, PA 17111 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. Comments $9,858.00 $13,767.61 !?ata li - descrFption 02/01/12 - 02/12112 02/01/12 -02/29/12 02/13/12 - 02129/12 03/01/12 - 03/31/12 03/01/12 - 03/31/12 04/01/12 - 04/30/12 04/01112 - 04/30/12 04/03/12 - 04/03/12 04/08/12 - (M/08/12 04/14112 - 04114/12 04117/12 - 04/17112 04123/12 - 04123112 04/28/12 - 04/28/12 04/30112 - 04130/12 04130112 - 04130/12 04/30/12 - 04/30/12 04130112 - 04130/12 04/30/12 04130/12 05101112 05131112 Balance Forward Room & Board Room & Board Room & Board Room & Board Room & Board Room & Board Room & Board Pullups - Large Pullups - Large Pullups - Xtra Large Pullups - Large Pullups - Large Pullups - Large Telephone Basic Charges Oxygen Cyclinders Oxygen Contractor/ 30 days Pharmacy Pharmacy OTC Room & Board Darts/ Rate it Units (12) 29 (17) (31) 31 (30) 30 1 1 1 1 1 1 1 11 1 1 1 31 TOTAL_ BALANCE DUE: $(318.00) $318.00 $(262.00) $(262.00) $318.00 $(262.00) $318.00 $15.38 $15.38 $15.07 $15.38 $15.38 $15.38 $30.60 $12.00 $90.00 $732.72 $86.46 $318.00 ACCOUNT NUMBER $43,32039 Charges/ 1 Payments (Credit) 1 $27,930.64 $(3,816.00) $9,222.00 $(4,454.00) $(8,122.00) $9,858.00 $(7,860.00) $9,540.00 $15.38 $15.38 $15.07 $15.38 $15.38 $15.38 $:30.60 $1:32.00 $90.00 $732.72 $86.46 $9,858.00 Balance, $27,930.64 $24,114.64 $33,336.64 $28,882.64 $20,760.64 $30,618.64 $22,758.64 $32,298.64 $32,314.02 $32,329.40 $32,344.47 $32,359.85 $32,375.23 $32,390-61 $32,421.21 $32,553.21 $32,643.21 $33,375.93 $33,462.39 $43,320.39 $43,320.39 FACILITY NAME _ RESIDENT NAME _ ACCOUNT NUMBER _ CHURCH OF GOD HOME, INC JEAN E HOCKENBERRY 803010 __ _? IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., PLAINTIFF, VS. JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, DEFENDANTS. CIVIL ACTION- EQUITY DOCKET NO.: 1 - 3S a7 ?i vi ! I?II1 PETITION FOR PRELIMINARY INJUNCTION AND NOW COMES, Church of God Home. Inc. ("Church of God"), by and through its attornevs., SCHUTJER BOGAR., and files the following Petition for Preliminary Injunction against lean Hocker,berry, by and through her Agent, Barbara Pugh, and Barbara Pugh. inclividually collectively -Defendants"), pursuant to Pa.R.C.P. § 1531, and, in support thereof. av ers: I Contemporaneous with the tiling of this Petition. Church of God is filing its ?_'omplaint against Defendants. See Complaint attached hereto as Exhibit The Complaint sets forth an equitable claim against Defendants relating to their breach ol'tl?w Nursing Care Admission Contract ("Agreement") that Defendant Barbara Pugh ("Defendant Pugh") entered into in conjunction with the admission of !ier mother. Defendant lean Hockenberry ("Defendant Hockenberry"), to Church of God's skilled nursing facility. See L)reement attached to Complaint as Exhibit "B." ORIGINAL Specifically, the Complaint alleges that Defendant. Pugh breached her contractual obligations under the Agreement by failing to timely qualify Defendant Hockenberrv for Medical Assistance benefits, including Defendant Pugh's continued refusal to provide to the Huntingdon Count Assistance Office ("CAO") the verification information and documentation necessary to process and approve Defendant Hockenberry's pending Medical Assistance application. I Moreover, in the Agreement, Defendant Pugh assigned to Church of God i)efendant Hockenberry's right to Medical Assistance benefits (hereinafter "the Assignment (_ lause") Sec Exhibit `B." Accordingly, Church of God now stands in the shoes of the assignor and has assumed Defendant Hockenberry's rights with respect to her Medical Assistancc benefits. See I lorbal v_N,loxham Nat'l Bank, 697 A.2d 577 (Pa. 1997) ("[A]ssignee stands in the shoes of the >>ssignor and assumes the rights of the assignor") 5. An injunction is required to compel Defendant Pugh to cooperate in the Medical Assistance application and appeals process, provide all of the requested financial records and ollhcl information to the CAO and otherwise qualify Defendant Hockenberrv Ior Medical assistance benefits. The very nature of Defendant Pugh's actions present an issue of immediate and irreparable harm to Church of God, as Church of God cannot be compensated for the skilled nursing ser,,Iiccs it has provided, and continues to provide, unless Defendant Pugh immediately coopcratcs with the Medical Assistance application and appeals process and provides the requested verification information to qualify Defendant Hockenberry for N4edica, Assistance benefits. 8 The requested injunction would restore the parties to the status giio as it existed at the time of Defendant Hockenberry's admission to Church of God's skilled nursing facility and immediately prior to Defendant Pugh's breach of her contractual duties. 9 Greater injury would result from the denial of the requested injunction than from the granting of the same because absent the injunction, Defendant Pugh will be ahle to continue to refuse to cooperate, Defendant Hockenberry's pending application for Medical Assistance ,)melts will be denied, and Church of God's ability to receive compensation for the skilled nursing services it has provided and continues to provide under the Agreement krill be forever ost. 1 () Church of God's right to relief is clear. Sce Complaint, attached as Exhibit "1." ] `. A bond in the amount of One Hundred and 00/1010 ($100.00) Dollars should be adequate In .he event that it is later determined that the issuance of the instant petition was in error NNUEREFORE, Church of God respectfully requests that this Court enter an Order regwring tl,.e specific performance of Defendants' contractual obligations under the Agreement, ?TecificallN., requiring Defendant Pugh's immediate cooperation in tl-e Medical Assistance Miefits proc,.-.ss, including, but not limited to: a. Ordering Defendant Pugh to provide any and all financial records and/or other information necessary to qualify Defendant Hockenberry for Medical Assistance benefits wvithin five (5) days of this Order, R Ordering Defendant Pugh to take any other action necessary to gi.talFf Defendant 1Iocicenberrv for Medical Assistance benefits within live (5) days of written notice by t'hiii-ch of God or the Huntingdon County Assistance Office. including but not limited to., the proper spend down of any of Defendant Hockenberry's excess assets and,/or resources iii accordance with applicable Medical Assistance regulations, if necessary; and ('. An`,, ether equitable relief that this Court deems just. Respectfully submitted. SCHUTJER BOGAR z. - y. Dated: _ B r Ivana ujic, Esq. PA Attorney I.D. No.: 31 1922 309 Fellowship Road, Suite 200 Mt. Laurel, NJ 08054 Phone: (8561 533-2464 Fax: (856) 533-2461 Kirk Sohonage, Esq PA Attorney C.D. No.: 77851 1426 N. 3d Street, Suite 200 Harrisburg, PA 17102 Phone: (717) 909-8160 Fax: (717) 909-5925 Attorncys'.for• Church of God 4 EXHIBIT "1" (TO PETITION FOR PRELIMINARY INJUNCTION) Supreme Cour"tbff-nnsylvania Court i)[, on!iuot ,.['leas z C ? il;Covel S1 het CU BLAND Count -4 y S E C T t O N A For Prothonotary Use Only: Docket No: i he informcx`,ioil collected on this form is used solely for court administration purposes. This f)rm does not srtnOlement or replace the filinv and service ofnlendinvc or nther nnnvre nc ronuirod by Ln„ nee i-iJov „f,,, -y Commencement of Action: ? Complaint ? Writ of Summons ? Petition ? "transfer from Another Jurisdiction ? Declaration of Taking Lead Plaintiff's Narne: Lead Defendant's Name: CHURCH OF GOD HOME, INC. JEAN HOCKENBERRY Are money damages requested? ? Yes No Dollar Amount Requested: ?within arbitration limits (check one) ?outside arbitration limits Is this a Class Action Suit? ? Yes 0 No Is this an MDJAppeal? ? Yes No Name of PlaintiElAppellant's Attorney: IVAN A GRUJIC & KIRK S. SOHONAGE, SCHUTJER BOGAR ? Check here if you have no attorney (are a Self-Represented [Pro Se] Litigant) 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. S -E C T O N B TORT (do not include Mass Tort) ? Intentional ? Malicious Prosecution Motor Vehicle ? Nuisance ? Premises Liability ? Product Liability ddoes not include Ynass tort, ® Slander/Libi;U Defamation Other: MASS TORT ? Asbestos Tobacco ? Toxic Tort - DES ? Toxic "fort - Implant ? Toxic Wastc [] Other- PROFESSIONAL LIABLITY ? Denial ? Legai kledic U Other Pro*essional CONTRACT (do not include Judgments) 0 Buyer Plaintiff ? Debt Collection: Credit Card ? Debt Collection: Other Employment Dispute: Discrimination ? Employment Dispute: Other ? Other: Specific Performance/ Breach of Contract REAL PROPERTY Ejectment Eminent Domain/Condemnation Ground Rent ? Landlord/Tenant Dispute Mortgage Foreclosure: Residential ? Mortgage Foreclosure: Commercial ? Partition ? Quiet Title ? Other: CIVIL APPEALS Administrative A<.,encies Board of Assessment ? Board of Elections Dept. of"Transportation © Statutory Appeal: Other ? Zoning Board Other: MISCELLANEOUS ® Common Law/Statutory Arbitration © Declaratory Judgment R Manclamus Non-Domestic Relations Restraining Order © Quo Warrant(, © Replevin © Other: Updated 1,1112011 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., PLAINTIFF, CIVIL ACTION- EQUITY VS. DOCKET NO.: JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, DEFENDANTS. NOTICE TO DEFEND Pursuant to Pa. R.C.P. 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 o; 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. HEIR OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A !_,A WYER. IF' ','OU CANNOT AFFORD TO HIRE A LAWYER, THEIR OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER l,E(IA1, SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FE1=. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., PLAINTIFF, CIVIL ACTION- EQUITY Vs. DOCKET NO.: JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, DEFENDANTS. AVISO PARA DEFENDER Conforme a Pa. R.C.P. Num 1018.1 USTED HA SIDO DEMANDADO/A EN COUTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de ios proxiinos veiente (20) dias despues de la notification de esta Demanda N, Aviso radicando personalmen*.e 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 eomo se describe anteriormente. et caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamation o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad a otros derechos i in porta.ntes para usted. LISTED DEBE LLEVAR ESTE DOCUMENTO A St.) ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIF..NTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI ISTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES I'OSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A I''ERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 (717) 249-3166 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC., PLAINTIFF, CIVIL ACTION- EQUITY VS. JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, DOCKET NO.: 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 Jean Hockenberry, by and through her Agent, Barbara Pugh, and Barbara Pugh, individually (collectively "Defendants-) and in support thereof avers 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 80" North 1-lanover Street, Carlisle, Pennsylvania 17013. Defendant Hockenberry ("Defendant Hockenberry") is an 81 year-old adult individual who is a current resident of Church of God's skilled nursing, facility located at 801 North Hanover Street, Carlisle, Pennsylvania 17013. 3 Defendant Barbara Pugh ("Defendant Pugh") is an adult individual, who upon information and belief, currently resides at 5470 Union Deposit Road, Harrisburg, Pennsylvania 171 11 and is the daughter and attorney-in-fact for Defendant Hockenberry. A true and correct coPv of the December 8, 2005 Power of Attorney document is attached hereto as Exhibit "A" and incorporated by reference. 4. Except for periods of hospitalization and short stays az home, Defendant Hockenberr:1 has been a resident of Church of God's skilled nursing facility since approximately March 30, 2010. At the time of Defendant Hockenberry's admission to Church of Nod's skilled nursing facility, and at all times relevant hereto, Defendant Pugh was operating as Responsible Party and attorney-in-fact for her mother, Defendant Hockenberry. t On or about March 30, 2010, Church of God and Defendant Pugh entered into a written Nursing; Care Admission Contract ("Agreement"), pursuant to which Church of God agreed to provide Defendant Hockenberry with skilled nursing services in exchange for, inter ilia. Defendant Pugh's promise to pay a specific monetary fee from Defendant Flockenberry's resources and promise to "complete the application and enrollment process for Medical Assistance benefits ... in a timely manner." See Paragraph 2 on page 9 of Agreement. 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 Hockenberry's right to apply for and obtain Medical. Assistance benefits ("Assignment"). See Exhibit B, Paragraph 14 on page 51 Specifically, the Assignment provides that "The Resident irrevocably authorizes the facility to make claims and to take all such other actions as maybe necessary for -+Iic Facility's receipt of third-party payments. To the fullest extent permitted by law, the Resident hereby a3ssigns now or hereafter payable to the extent of all charges due to the endorse and turn over to the Facility,- any payments received from third-parties to the extent necessary to satisfy the d harges under the Agreement." 2 ,. After Defendant Hockenberry became a resident of Church of (.iod's skilled nursing facility. her bills for the necessary skilled nursing services provided by Church of God event unpaid. Ci. As a result, an application for Medical Assistance benefits was filed on Defendant Flockenberry's behalf with the Huntingdon County Assistance office ("CAO") on or about April 7. '10J7 1l'. Said application is currently pending with the CAO. However, the i='AO will not approve said application unless and until Defendant Pugh provides the CAO with the personal and financial verification necessary to determine Defendant Hockenberry's eligibility for Medical Assistance benefits. 1. Unless Defendant Pugh is immediately compelled to produce t9ie requested verification information and documentation required by the CAO and otherwise take the actions necessary to qualify her mother for Medical Assistance benefits, Defendant flockenberry's application will be denied and months of retroactive Medical Assistance benefits will be lost for Defendant Hockenberry. 1 ?. In accordance with the Agreement, Church of God has provided room, board and skilled nursing care services to Defendant Hockenberry and continues to do so. Li. However, in breach of the Agreement, Defendant Pugh has refused to cooperate with Church of God's efforts to qualify Defendant Hockenberry for Medical Assistance benefits. 11. As a result of Defendant Pugh's failure and/or refusal to cooperate with the Medical Assistance application and appeals process, an outstanding balance of Forty-Three Thousand. Three Hundred Twenty and 39/100 ($43,320.39) Dollars, plus interest, costs, and attornevs' f:es, remains due and owing to Church of God for the cost of Defendant 3 HockenbetT.,'S skilled nursing care since her admission to Church of God.' A true and correct copy, of the ;nvoice is attached hereto as Exhibit "C" and are incorporated by reference. COUNTI BREACH OF CONTRACT - SPECIFIC PERFORMANCE PLAINTIFF v. DEFENDANTS 14'. The allegations contained in Paragraphs 1-14 are hereby incorporated by reference as if fully set forth herein. 1 O. Pursuant to the Agreement entered into with Church of God, Defendant Pugh agreed. irater• alia. to cooperate fully with the Medical Assistance application and appeals process. S.ee Exhibit "B." 17 Church of God has provided, and continues to provide, Defendant Hockenberry with skilled nursing care services pursuant to the terms of the Agreement. is However, in breach of the Agreement, Defendant Pugh has failed to timely qualify Defendant Hockenberry for Medical Assistance benefits and has refused to cooperate with Church of God's efforts to secure Medical Assistance benefits on Defendant Hockenberry's behalf. 1 ). Specifically, Defendant Pugh has refused to cooperate with. Church of God's efforts to complete the pending Medical Assistance benefits application and has refused to provide to the CAO the financial verification necessary to qualify Defendant Hockenberry for Medical Assistance benefits. This amount will increase by a minimum of Ten Thousand ($10,000.00) Dollars for every month that Defendant Hockenberry continues to receive skilled nursing care from Church of God and fails to secure Medical ;assistance benefits to cover the same. 4 20. If Defendant Pugh continues to refuse to cooperate in the Medical Assistance eligibility and appeals process, the pending Medical Assistance benefits application will be denied, Defendant Hockenberry will not be eligible for Medical Assistance benefits, and Church of God will have no way to recoup the outstanding balance due and owing to them for skilled nursing services it has provided and continues to provide to Defendant Hockenberry. 21 Defendant Pugh's breach of the Agreement with Church of God has irreparably harmed and continues to cause Church of God irreparable harm. 22Only 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 and Assignment. WHEREFORE, Church of God respectfully requests that this Court enter an Order requiring the specific performance of Defendants' contractual obligations under the Nursing ('are Admission Contact specifically ordering Defendant Pugh's immediate cooperation in the Medical Assistance benefits application and appeals process, including, but not limited to: A. Ordering Defendant Pugh to provide any and all financial records and/or other information necessary to qualify Defendant Hockenberry for Medical Assistance benefits within five (5) days of this Order; B. Ordering Defendant. Pugh to take any other action necessary to qualify Defendant Hoc:kenberry for Medical Assistance benefits within five (5) days of written notice by Church of God or the Huntingdon County Assistance Office, including but not limited to, the proper spend down of any of Defendant Hockenberry's excess assets and !or resources in accordance with applicable Medical Assistance regulations; and 5 C. .tarry other equitable relief that this Court deems just. Respectfully submitted, SCHUTJER BOGAR Dated: ry - t7-- By: Ivana Grujic.. Esq. PA Attorney I.D. No.: 31 1922 309 Fellowship Road, Suite 200 Mt. Laurel, NJ 08054 Phone: (856) 533-2464 Fax: (856) 533-2461 Kirk Sohonage, Esq. PA Attorney I.D. No.: 77851 1426 N. 3d Street, Suite 200 Harrisburg, PA 17102 Phone: (717) 909-8160 Fax: (717) 909-5925 Attorneys for Church of Gocl 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. 1 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. 9 1 ?. r Dated: _?-l'_?-•?C? --? Sharon Cramer, Representative of Church of Clod Home, Inc. EXHIBIT "A" (TO COMPLAINT) s vsr4svt???nuw>ut?,uiu? i.?.i». 4R ANAl RUTNNUD m ?? LAW p(Ri:Es ?QtL on eaid,a 7 vV 1?jwn: , & Otto A PAWW C0RPC9A7l0N nN EW NGH SIRE6r POWER OF ATTORNEY CA=LPA IM13 IJ f 712/33311 JEAN E. HOCKENBEARY to JOHN C. HUCK.ENRERRY or BARBARA. A. PUGH NOTICE THE PURPOSE OFTJHS POWER, OFATTORNEYIS TO GIVE 2WEPERSON YOU PaiGNATE(yOURt`, oEN. umiza4DPOWMUTOH.4"LEYOURPROPER7T, WWCH MAY INCLUDE` POW ERs TO SEU OR OTHIMIffSE DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUTADVANCENOTICETO YOUORAPPAOYAL BYYOU THISROM 0FA77ORNEYD0ZN0TIMP0SHADU7YON YOUR AGWT TO EXERaSEGRAN1ZD POW ' ' , )3VT OHENPOWERSAREF.X,is"RCISED, YOURAGENT MUSTUSEDUZC ETOACTFORYOURBEAT ITANDINACCORDA:NCBB''ITHTHXS POMA OFATTORNEY. YOVBAGENTMAYEXBRCIS.B THE.POWFM GIVENHaS THROUGHOUT YO UR MFET,l1ME.YENAMR YOUAWOHEINCAPACITATED, UlVLES$ Y0VRXPRES,SLY LIMIT' THE DUX4TI'ON OF THESE POW,BRS'OR YOUBEVOKK T'k=E POWERS OR A COURT ACTING ON YOUR BEHALF x.BRMI'NATES YOUR AGENT'S AUTFIORITY, YOUR AGENT M MIST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS. A COURTCANTAKEAWAYTHEF0WERSOFYOURAGENT ,IFITFIND,SYOUR AGENT IS NOT ACTING PROPERLY THE POWERS AND DUrI.ES OFANA, GENT UNDER A POWER OF AI TORN,RY ARE EXPLAINED MORE FQLLY 27V THE PENNSYLVANIA PROBATE, EST4.TES AND FIDUCIARIES CODE, 20 PA. C-S.A. CHAPTER 56, Iii'THEREISAJI'YTH NGAP-0VTTHIS.FORMrHATYOUD0NOTUNDERSTANb, YOU SHO ULD ASK A LA WYEIt OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU. J )M YE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS CONTENTS. Datc: I _ CL-s ]can E. Hocke eny ? ?? 7boT ?ou 01[wI n1011 1 , Y 1w4•, ..??- , 1, JEAN E. HOCKENBERRY, of 1464 Walnut Bottom Road, Carlisle, PA 17013, hereby revolve any general power of attorney that I have heretofore given to any person and do hereby appoint my husband, JOHN C: MOCKENBERRY, of 1464 Walnut Bottom Road, Carlisle, PA 17013, or in the event he is unable-,or unwilling to so act, then I appoint my daughter, BARBARA A. PUGH, of 5470 Union Deposit Road, Harrisburg, PA 17111, as cny, agent(s). ("my agernt'j, with full power of substitution, for me and in my name, to ttansact all mybusiness and to manage all my property and affairs as I might do if personally present, including but not limited to exercising the following powers. Ourable Power of Attorney This power of attomey shall nat be affected by my subsequent disability or incapacity. All acts done by my agent pursuant to this power during any period of my disability or incapacity shall have the same effect and enure to myboneftt and hind me and my successors in interest as if I were competent and not disabled. Powers of A:gtut I hereby empower my agent to-do any or all of the following, each of which is fully defined and explained in Section 5603 of the-Pennsylvania Probate. Estates and Fiduciaries Code, 20 pa. C,S.A. § 5603, to 'include, without limitation, all amplification of such powers as specified therein: 1. To make gifts onmy behalfwlach tyre limited to the class ofpenons consisting solely of-my spouse, my issue, rind my agent ifhe or she is amember of such class, or any of them. During each calendar year, the gifts made to any permissible donee, pursuant to snch.powor, shall have an aggmpte value not in excess of; sold shall be made in such ,manner arl to qualify, in their entirety, for the annual exclusion from the federal g& tax permitted tot myself, and if applicable, my spouse. In addition to the gifts authorized above, a gift made pursuant to such power may be for the nation or medical can of any permissible donee to the extent that the gift is excluded from the federal gift -tax as a qualif cd transfer. My agent may consent, pursuant to the ?atcmal Revenue Code, to the :splitting of gifts made by my spouse to my issue or a spouse of my issue in any amount and to the splitting of gifts made by my spouse to any otherpcrsonin amounts not:exeneding the.aggregate annual gift tax exclusion for both myself and my spouso under the Internal Revenue Codc: To create- a trust for my benefit. To alter, amend or revoke and to make additions to an existing trust for my benefit. 4 To claim an elective sharo of the estate of my deceased spouse. To disclaim any interest in property. 6. To renounce fiduciary positions. -2- tQ7 'ON T To withdraw and receive the income or corpus of a trust. S. To authorize, my admission to a medical, nursing, residential or similar facility and to enter into agreements foamy care, (See Exhibit "A" attached hereto.) ). To authorize: medical and surgical procedures. (Sec Exhibit "A" attached hereto.) .1 b. To engage in. real property transactions. 11. To engage in tangible personal property- transactions. 12. To engage it, stock, bond and other securities transactions. 13, To engage in commodity and option transactions. 14. To engage in banking and financial transactions. 15. To borrow money. 16. To enter safe deposit boxes. 17. To engage in insurance transactions. 18. To engage in retirement plan transactions, including to designate one or more beneficiaries orcontingent beneficiaries for any bcnelits under such plan on account of my death and to change any such prior designation of beneficiary made by me or by my agent; provided, hovevcr, my agent shall have no power to designate h trtselfYhozsolf as a boncficiary or contingent beneftciaryto receiver a greater share of any auchbcmfits than holshewould have otherwise received unless such change is consented to by all other beneficiaries who would bavc received the benefits but for the proposed change, 14, To handle interests in estates and trusts. 20. To pursue claims and litigation. 21, To rcceivc governrncnt benefits. 21 To,pursue tax matters. 23. To make an anatomical gift of all or part of my body, 24, To do all other things which my agent shall deem necessary and proper in order to carry out the foregoing powers which shall be construed as broadly as possible. -3 - v ti,W'ON gNVIIIRAHe A11INV? wuit-ii ?.in? r Reliance ou Power 'T`his power may be accepted and relied upon by anyone to whom it is presented until such person either reccivas written notice-of revocation by me or a guardian or similar fiduciary ofmy estate or has actual knowlulge'of my death. 1 hereby authorize and empower any successor agent to certify to the-death, inability or unavailability of anypredecessor agent to function hereunder, and I hold harmless anyone who relie.9- on'such Certification. Hold Harmless All actions of my agent shall bind me and my heirs, distributees, legal representatives, successors and assigns, and for the purpose of inducing anyoncto act in Accordance with the powers I have granted herein, I hereby represent, warrant and agrea that if this power of attorney is tamtinated or amended for 8nyzeasm I and mybt irs, distributees, legal representatives, successors and-assigns will hold such party or pmties harmless from any loss suffered or liability incurred by such party or panics. while Meting ih accordance with this power prior to that party's receipt of written notice of any such termination or amendment Pennsylvanin Law. Goveras Qatstions pertais&g to the validity, construction and Mowers created under this instrument shall be determined in accordance with the laws of the Cammonwcalth of Pennsylvania. Signed this day of bu- WITNESS: ?Jean E, Hockenberry COMMONWEALTH OF PENNSYLVANIA SS. COUNTY" -Of CUMBERLAND ) On this the day of ' before me the undersigned officer, personally appeared Jean E. Hockenberry, Principal, the peireon whose name is subscribed, to the within instnrment, and aeknowledged that she executed the same for the purposes therein contained, IN WITNESS WHEREOF, I Hereunto set my hand art eial seal. /?," __(SEAL) Notary Public Np1MAt SEAL ` I VICTORIA t. OTTO NOTARY PUBLIC CARLIStt $ORO. CNI)ERtAND COUMY NY M19. 1 ti X IRES 0 C. ab ` .q. 4 Tb41 ON 0 ?ikt % 1 0 1 U J s-..t1uut Wvfi- 0.1/ ?WZUI n 17: ay 717-2( . B50 MARTSON LAW PAGE 02/03 ?-` ?T DECLARATION I, Jean E. xockenberry, being of sound, mind, willfully and voluntarily make this deglaration to be followed if I become incompetent. This declaration reflects my firm and settled commitrnen:t to refuse line-sustaining treatment under the circum- stances indicated below.. I direct my attending physician to withhold or withdraw life-sustaining treatment that serves only to prolong the process of my dying, if I should be in a terminal condition or in a state of permanent unconsciousness. I direct that treatment be limited to measures to keep me comfortable and to relieve pain, including any pain that. might occur by withholding or withdrawing life-sustaining treatment. In addition,, if i am in the condition described above, I ,feel especially strong about the following forms of treatment Z ( ) do " do not want 08xdlac TesusCita.tion, I ( ) do (s? do not want mechanical respiration, r { ) do (y? do not grant tube feeding or any other artiti-- cial or i,nvasi:vs form of nutrition (food) or hydration (water)„ :C do dp not want blood or blood products. ?, ( } do (?C) do not want any form of surgery -or invasive diagnostic tests . ?, t ) do (? do not want kidney dialysis. .fin s t?9 da «o not want antibiotics.rSto? r. I realize that if I do not specifically indicate cry prefer- ence regarding any of the forms of traat:m®nt listed above, I may receive that form of treatment. C rj L V 1 J: C17 1 /-! 2 W)u MARTSQN LAW PAGE 03/03 Other instructions: T (PI do ( ) do not want to designate another person as my surrogate to make medical treatment decisions for me if x should be incompetent and in a terminal condition or in a state of permanent unconsclousness. Name and address of Surrogate (if applicable) : 1-9 zu Name and address of substitute surrogate (if surrogate designated above is unable to serve) : 3 made this declaration on the day of jn??ep can E. ltookenberrp 1464 WA nut Bottom Road Carlisle, PA 17013 The decl:arent or the person on behalf of and at the direc- tion of the declarant knowi:ngl.y and voluntarily signed this writing by signature of mark in my presence. 'Address Address: C441taIe. ?A 1700 4M!b? CHURCH Of GOD HOME "Committed to Curing" Nursing Care Admissions Contract Information 1 Church of God Home, Inc. 801 N. Hanover Street • Carlisle, PA 17013 P: (717) 249-5322 - F: (717) 249-8622 Reuised 1112009 l 1 42? CHURCH OF GOD HONE "Committed to CorrnK` 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 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 supporl....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 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 4e. 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 Welcome Letter.. .. ............................................................... ......... ...... ............. ............. ..... .. 2 2. Statement of Vision and Mission ......................................................................... ............ ....... ..4 1 Ambulance ................................................................................................................... ..........4 i 4. Chart of Costs.. ... .............................................................................. ........ ......... I ........ . 5-7 5. Dietary Services ........................................................................................................... ........ 7 -8 6 DVD "A Time of Transition" ............................................................................................. ...........8 7 Guest Room .............................................................................................................. 8, Lehigh Valley Respiratory Care - Lancaster ................................................................ ...........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 11 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 21 Non-Discrimination Statement ....................................................................................... ......... 23 24. Personal Cash Accounts 1 Depleted Funds .................................................................... .... 24-25 25. Personal Laundry Service ............................................................................................. ......... 26 26. Pharmacy Services ..................................................... --............ ..,......... ......... ......... ..... .... 27-34 27. Podiatry Services. ............ ................................................... .......... ....... ........ .............. ......... 35 j 28. Privacy Act Statement - Healthcare Records ................. .. 36-37 29. Private Room Policy / Nursing ........................................................................................ ......... 38 C 30. Therapy ......................................................................................................................... ......... 39 31. Vaccinations . ....40.45 f 32. Valuables ........................................................................................................................ ......... 46 33. Admission and Care Agreement .................................................................................... .... 47 -55 a. Security Deposit .................. ........................................................... ......... 47 b. Readmission - Bed Hold Policy .... 49 l 34. Resident / Family Guide to Inquiries and Information ..................................................... .... 53-54 35. "k-'Jelcome' (Telephone/Extension) ............................................................................... ........ 55 36. Checklist .......... _ ....................................................................................................... ......... 56 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 eligibi1ty for, or in any manner of, providing any resident service that is provided by or through the facility. ! All areas of the healthcare censer 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 Is 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 $241.00 per day Private $296.00 per day Personal Care Room Rates Effective January 1, 2010 Hope Wing and Peace Wing . Semi-Private $107.00 per day (Rm401A11) Private $115.00 per day (Rm301) $126.00 per day (Rm303-313) $134.00 per day (Rm400) Creekside_ Apartments Studio One Bedroom One Bedroom, Creek view One person $149.00 per day $169.00 per day $174.00 per day Two persons $251.00 per day $277.00 per day $323.00 per day Note: There will be a security deposit charged based on a 31-day month at the per diem rate for roomllevel 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 Fee One Person Two Persons A $914 $1,227 B $843 $1,136 C $843 $1,136 L $828 $1,126 E $828 $1,126 i Apartment Type 40% Refundable Rate Apartment "A" $109,000 Apartment "B" $96.100 Apartment "C" $96,100 Apartment "D" $81,000 Apartment "E" $81,000 Independent Living Rates Creekside Apartments Apartment Monthly Fee One person Two Persons Efficiency $1,318 $1,803 One Bedi0 cm $1,667 $2313 Non-Refundable $83,000 $73,000 $73,000 $63,000 $63,000 5 Chart of Costs (continued) Bed Hold (during hospitalization or LOA) 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 Beefs / Pull-ups Miscellaneous supplies Laundry Service (personal clothing) Medication itself administered medication) Photocopies (copies of records) Therapy (physical, occupational, speech) Private Telephone Purchase Telephone Set Monthly Line Fee Hook-up, Activation, One Outlet (one time charge) Dietary Services (guest meals; includes tax) Breakfast Dinner Supper Sundays and Holidays Nutritional Supplies Extra Dietary Service Medications, Medical and adaptive equipment, Alarm pads, special requests, etc. Transportation Services Oxygen Concentrator Usage, Portable Oxygen Usage CPAP, BIPAP and Supplies Per Diem rate 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 25% above cost 25% above cost $33.751month $15.00/month $1.28/pg(1-20) $0.95/pg(21-60) $0.32/pg(61+) Actual cost unless covered under Medicare or co-payment by secondary insurance At own expense $30.601month No Charge $5.00 $7.65 $6.30 $7.65 25% above cost Contact your social worker At own expense unless covered by your insurance or covered by medical assistance benefits 0-10 Miles (round thp).... _.............. 122.00 11-50 Miles (round trip) ............ ... $44.00 51-76 Miles (round trip)............ $75.00 Escorts..... . $10.00/hour $3.00/day, unless covered under Medicare $12.00/cylinder, unless covered under Medicare Actual cost 6 Chart of Costs (continued) Hair Care Frost $48.00 Cut, Men $11.25 Cut, ;mash, blow dry $26.00 Cut, Women $12.25 Hot wax $7.15 Men's cut and moustache trim $12.55 Oil treatment, shampoo, set $24.50 Permanents $54.05 Permanents in bed $59.50 Wash, no blow dry $8.45 Men's/Women's cut-wash in bed $28.35 Color rinse $1.05 Dietary Services Cut, wash and set $25.00 Re-comb $8.45 Re-comb and curling iron $11.75 Tint $28.60 Wash and set $12.75 Wash, blow dry $13.80 Men's/Women's wash in bed $16.10 Wash, style, blow-dry in bed $29.40 Men's cut - wash $19.65 Mustache trim $1.30 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 three-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 WTAX 9" Round_- 2 layers 16 i - _ $15.00 _ '/< Sheet - 10"x14" 16 $15.00 % Sheet -12"x17" 30 ---- _ $20.00 ---- -Fulii sa $30.00 i ICE CREAM: Hand dipped - dishes $1.00 Hand di .d - 3 gal. container $17.50 Dixie Cups - (24) 4oz. containers Vanilla / Chocolate $10.00 I 4 GUEST MEALS: Breakfast - ; -$5.00 - -- Dinner__- - - - -- - ---- $7.65---- Supper --- - $630 ----- f Sunday. and Holiday $7.65 I MISCELLANEOUS: Potatoes Chips _ 3 Ibs_ s_ $9.75 ` j Pretzels -3 lb. _ $7.55 _ I 4 Punch -1 gal. $4.00 -- Lemonade -1 gal. - -- -- ; -- $4.00 - Iced Tea -- 1 gal. - $4.00 I Cookies -1 doz. Any Kind --- $3.50 i NOTE: All of the above items include paper-serving Products and must __ be ordered 1 week in advance. Special Orders will be pr-iced by Dietary Department t DVD "A Time of Transition" i i 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 Ins urance, the Home's insurance I company, recommends a viewing of this DVD. (- _-. initials) a 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 LEHIGH VALLEY RESPIRATORY CARE - LANCASTER 1176 Enterprise Court - East Petersburg, PA 17520 (717) 569-4667, 1-800-952-8452, Fax (717) 569-5555 Lehigh Valley Respiratory Care - Lancaster is an independent Home Medical Equipment Company providing respiratory services to Long Term Care Facilities. We are accredited by the Joint Commission of Accreditation of Healthcare Organizations to perform Clinical Respiratory Services. Lehigh Valley Respiratory Care - Lancaster provides Church of God Home residents with oxygen and respiratory supplies. The Church of God Home will contact Lehigh Valley Respiratory Care - Lancaster for these services when initially needed. Personal Care Residents: • Lehigh Valley Respiratory Care - Lancaster will then contact the Resident/Responsible Party to schedule the arrangements and discuss their billing procedures. • Oxygen J Respiratory Supplies may be covered under Medicare Part B as long as the qualifying criteria have been met. • Lehigh Valley Respiratory Care - Lancaster will contract with the ResidenVResponsible Party on an individual basis and will bill Medicare Part B directly. 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 administrative and operating procedures. Medicaid's major distinction from Medicare is a f of financsal`ai`de Medicare is a type of healthcare 11 insurance. When resident resources are re to $15,000.00, the facility Business Office should be notified immediately. The following instructs will apply: 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 Assessmerif 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 residentlresponsible party regarding available options. 9 4 To appeal a decision regarding a Medicaid Assessment, contact: The Pennsylvania Department of Public Welfare Centre County Assistance Office (Cumberland County Long Term Care Unit) 2580 Park Center Blvd State College, Pennsylvania 16801 P: (814) 863-6571, 800-355-6024 Fax: (814) 689-1356 To appeal a decision regarding a level of care assessment, contact: The Cumberland County Office of Aging Long Term Care Program Human Service Building 16 West High Street 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. 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. 10 424 CHURCH OF GOD HOME "Committed to Curing" Medicaid (Medical Assistance) Residents The Church of God Home, Inc. requires a copy of monthly / quarterly Medical Insurance premiums. As REQUIRED by Pennsylvania State Regulations. ` 2. Medical Insurance Premiums will be deducted from the Resident's monthly income and the balance of the income less a 5.00 allowance will be applied to room and board. 3. Prescription drugs, physician visits, dental services, and eye examinations are covered by Medicaid, but only with participating dentists 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 j 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 i The following services will be charged: Any hair care request beyond the above list of provided services Transportation for a personal use • Telephone hook-up, 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 yea . (Date) (Resident/Responsible Party) fl Medicaid (Medical Assistance) Resident's Checklist CENTRE COUNTY ASSISTANCE OFFICE (Cumberland County Long Term Care Unit) 2580 Park Centre Blvd State College, Pennsylvania 16801 Telephone: 1.800.355-6024 or (B14) 863-6571 ¦f 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) ..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 nterest income 10. Provide current statements for ALL bank accounts, stocks, bonds, trusts, IRAs, Keoghts, and Annuities - must provide values of 1' . °ersonal Care Account (PCA) Balance 12. 'Verification of all resources sold, transferred, or given away during the past 5years (5 years for a Frust Fund) - provide disposition, amounts, and dates 13 Titles, vehicle regislration, and insurance for all vehicles owned, including boats, motorcycles, j :ind 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. _ 1,1:1, Deed to burial plot(s) or statement from cemetery J._ 16 Copy of Burial Trust! Reserve (including Statement of Irrevocability) Deed to all properly 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 113 Title to mobile home and it's current market value - if transferred or sold within the last _ 5 years, provide a copy of the now 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 ! . Utility Bills A. Electric B. Gas G. 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 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 i 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. 11 1 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 f 5. The Medicare intermediary or the facility's Utilization Review Committee does not disapprove your stay. i 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. I 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 13eriod, but only if you need daily skilled nursing care or rehabilitation services for that long. 14 It 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 100 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 $137.50 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-RaylUltrasound/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, PC 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 tc 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.. Ali 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 five 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) 238-6070. 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 ML 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 ger 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 i . 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: II 18 42?? 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. 1 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. 24 (Date) 19 ( esidenSesponsible Party`, CHURCH Of GOD i HOME f "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. E 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 Horne or DPW regarding care, operations, or management of the Home shall be directed to the Administrator of the facility. 2. It a resident wishes to make a written complaint but needs assistance, the PCU Administrator 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 biAr. (Da'e) 20 W! 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. - '". is medically/physically capable of I e of silent) y &"&& understanding Resident's Rights but designates this to: (Date) esidenWesponsible Party) 21 42?4 CHURCH Of GOD HOME "Committed to Caring' ¦, 1! 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 NURISNG 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 16 West High Street Carlisle, PA 17013 Telephone: 717-240-6110 f (Date! PENNSYLVANIA DEPARTMENT OF AGING 555 Walnut Street Harrisburg, PA 17101 Telephone: 717-783-7247 PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE CENTRE COUNTY ASSISTANCE OFFICE (Cumberland County Long Term Care Unit) 2580 Park Center Blvd State College, PA 16801 Telephone: 814-863-6571 1-800-355-6024 MID PENN LEGAL SERVICES 401 East Louther Street Carlisle, PA 17013 Telephone: 717-243-9400 22 (R ideZResponsible Party) 42b? 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: • T. 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: d President/CEO Church of God Home, Inc. 801 N. Hanover Street Carlisle, PA 17013 Phone: (717) 249-5322 Pennsylvania Human Relations Commission Harrisburg Region Office Riverfront Office Center 1101-1125 South Front Street, 5b Floor Harrisburg, PA 17104-2515 Phone: (717) 787-9784 (Date) Department of Health and Human Services Office for Civil Rights 150 S. Independence Mall West Suite 372 Philadelphia, PA 19106-3499 Phone: (215) 861-4441 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 23 Personal Cash Accounts (PCA) Yo estabLsh personal cash account (PCA) at the Church of God Home, Inc., contact our Business Office (Henderson House). The following procedure shall be followed: 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 Mote: Regular business hour,; 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. j 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. 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. 4R 24 Personal Cash Accounts (cont.) CHURCH OF GOD HOME "Committed to Caring" Authorization to Handle Personal Funds (Date) Depleted Funds When resident's assets reach $15,000.00, family/responsible party should contact our Business Office immediately. Family member / responsible party will have to apply for Medical Assistance. Residents with no family member / responsible party, our Business Office will apply for Medical Assistance. Residents will receive 5.00 monthly from their income for personal needs. Other monies may be r-4 n deposited into each PCA, as the resident or family membe r sponsible p "S. I'A?Isl 17. (Date) P(e!fiderittRsppconsible Party) (Resi t N e) V (:F (Facility Representa6v 25 k4V ) ft--- -- 42?? CHURCH OF GOD HOME "Committed to Caring" Personal Laundry Service This is to advise that the personal laundry will be laundered withi eoutsidercle one) the facility. NOTE: • These arrangements can be changed with notification to Social Services or Charge Nurse. • Residents I Responsible Parfies 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 1 personal items. Please contact Social Sehtiices or Charge Nurse. • Dry cleaning and Alteration Services are not provided. • No wool items are accepted. (Date) (Resident/ReWsible ParfA (R Name) j r (Facility Represents 26 Specialist In 28 SOLIth 2m 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 tablet/capsule 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 rneet 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-terra care industry. Note: Please contact Continuing Care RX with any questions or billing concerns at 1.800-675-2279 27 Pharmacy Services Privacy Notice 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 PH) 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 Notice, we will promptly post the revision [insert location, such as on a website). You also may request and obtain a copy of any new/revised 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. II. How We May Use and Disclose Your Protected Health Information 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 ynur 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 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: I, 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 aidedicchnicians. 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 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 PTfvacy Noiicx 28 'nF ocr.Vorr" ?. Use and Disclosures Rclated 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 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. III'. Uses and Disclosures Requiring Your Written Authorization 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 rime 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 Authorizationfor 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: 1 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 PH] 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 obiiect to the release of this information. You may use our Request to Restrict the Use or Disclosure of f'rctected 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 VI, paragraph 1.) V. Uses and Disclosures of Information That Do Not Require Your Consent or Authorization 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- L When Required by Law: We may disclose your protected health information when required by federal, state or local law Aivacy Notice 29 Prtwcy,voucr 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: To 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 Fec, Cross) to assist in diaaster relief efforts. 5. 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 a drug or medical device. 5. 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 civi l rights laws. A. To Coroners, Medical Examiners, Funeral Directors, Organ Proeurement Organizations or Tissue Banks: We may disclose your protected health information to a coroner or medical examiner foq 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. 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 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 ourposes. 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 &afety of others. When such disclosure is necessary, information will only be released to those law enforcement agencies cr 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 accordanec with our legal obligations. 30 e',ivacl Vonce 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 by law, 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 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 ar 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 in formation about your child to you without your child's written authorization. 15. To Persons] 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 ofcorrectional 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 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 such request in writing. Such request should be submitted using our Request to Restrict the Use and Disclosure ofProlected Health l*rmation form. Our contact information for purposes cf 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 Privacy Notre 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- I f 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 centact 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 heath information, we w'sll 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 arc 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; h. 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 amendmcnt/correetion request should be submitted on our Request for .4mendment'Correcrion 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. A- The Right to Request Confidential Communications: You have the right to request that we communicate with you about your health matters in a certain wav 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 of this 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 1'-i.=ac?Koiiu: 32 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, ctc.), 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 wilt be so notified. However; in no case will such extension exceed thirty (30) days. The first accounting you 'request during a twelve 1;12) month period will be free. There may be a reasonable fee for additional requests during F,he 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 Information 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: I You have the right to reeeive 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 we:bsite (as applicable). Our contact information is listed on the last page of this document. VI. How t0 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 filing a complaint. Ycu may submit your complaint on our Privacy Practices Complaint form available from our business office. Our contact informatior is listed on the last page of this document. f Privacy Ndicc 33 1"gvacy,vonce CONTI14l11NG CARE RX NOTICE OF PRIVACY PRACTICES Record of Acknowietigmetrt f Doctxnen on of cod Faith Effort to Obtain Acknowledgment Narre of (Residcnt/Patientj: Date-A/1 1 Effective Date of This Privacy Not 14, 2003 Contact Information for Questions, Complaints or Requests Regarding Your Health Information Should you have any questions concerning our pri2cy practices. obtaining a copy of our privacy notice, ,,.questing restrctions on the release of your information, revoking an authorization, amending or correcting your protected health information- obtaining an accounts g of our disclosures of your protected health information, requesting inspection or copying of your medical information, requesting that we communicate information about your health matters in a certain way, filing complaints, or any other cbneerns Iva may have relative to our privacy practices, please contact: Brian D. Stw alley Chief Compliance officer 5775 Allentown Blvd. Suite 202, Harrisburg, PA 17112 Tel: 717-810-1950 Ent- 4, Fax: 717-7910-1952 bstw•alley;ri?ccrz erg if feu 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. Dcpariment of Health and Human Services, 200 Independence Avenue, S. W., Washington, Dc' 2C20'1: ar you may call (202) 619-0257 or 1-877-696-.6775 (lo)l free): or you may log on to the intemet address, http •l/ww,W. hhs. goy/ocr. Acknowledgment / Good Faith Effort to Obtain Acknowledgment (check one of the following) f j 1 am the above Resident/Patient and I certify that I received a copy of the Continuing Cam 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 relative to the protection of my health information I am satisfied with the explanations provided to me and I am confident that Contimning Care Rx is committed to protecting my health information hate : Signature: -- Printed Name: J I certify that I am the authorized representative of above name Residem/PatieriL and that I have received the Privacy Notice on behalf of this individual and that Continuing Care Rr provided ,rte 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-named entity is committed to protecting health information. I. ) 11 _ _- certify that I made a good faith effort to obtain the acknowledgment of the above- identified fresident/patientj or his/her 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): J [Resident/Patieetj or personal representative refused to sign. ( j fResident/patienij or personal representative was unavailable to sign. I j Other: Date --- - Signature/Title: F4??•ac? A',?I?ci 34 i I 1 CHURCH OF GOD HOME 'Committed to Caring" i PODIATRY SERVICES i I request that payment of authcrized Medicare benefits be made either to myself, or on my behalf, to j Dr. William Puliq for any serviws 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 determine these benefits payable for related services. I 1 i Yes: I have accepted Dr. William Puliq as my podiatry care physician i No, I decline offered podiatry care physician for my podiatry care -mac---,, (Date) (R 'dentlResponsible Party) I ( nt Name) i (Facility Represen } ? I r 35 42, CHURCH OF GOD HOME ` Commuted 1o 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 (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 Reccrds. 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 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 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 (Date) 37 (Facility Represent CHURCH i OF GOD HOME "Committed to Coring" 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 pirivate nursing room in this facility may be used as a regular private/single room until the facility's need for an isolation room arises. This room is identified as Room 118 ( Faith Wind. 2. Any resident using room 118 must agree on admission that they will move out of the room to a semi-private room if the facility needs to use it. 3. When a need for an isolation room 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 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. 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. I (Date) (Re 'den esponsibre Party) n (Re ' en Name} _?_ 19 - /Y /1" ? - - - (Facility Represen ? 38 42?4 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. The ndersigned herby conse is to a prov' ion of therapy services for (the Resident) as ordered by Res' en physician and deemed necessary to attain or aintain the highest practicable physical, mental and choso,ial 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 necessar/ records needed for the provision of therapy services or for payment. 2 (Date) 39 r'1 i2-1i'dent(Responsible Party Vaccinations t 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 tunes can lead to death. The best way to prevent the flu Is by getting a flu vaccination each year. Every year in the United Staters, on average: 1 • 5% to 20% of the population gets the flu; more than 200,000 people are hospitalized from flu complications; and 1 • about 36,000 people die from flu. i 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 symptom, such as nausea, dry cough vomiting, and diarrhea, also can occur but • sore throat are more common in chilldren than adults Complications of Flu Complications of flu can include bacterial pneumonia, ear infections, sinus infections, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes. How Ru Spreads Flu viruses spread mainly from person to person through coughing or sneezing of people with influenza. Sometimes people may becorne 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 means that you may be able to pass on the flu to someone else before you know you are sick, as well 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 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 anc people with chronic medical conditions. Page i of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER -HEALTHIER •PEOPLE- ; I 40 Key Fads About Seasonal Influenza (Flu) Then asal -spray flu vaccine -a vaccine made with live, weakened flu viruses that do not cause the flu (sometimes called LAN for "Live Attenuated influenza Vaccine'). IAN is approved for use in healthy` people 249 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-Ifke 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 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 for high risk persons. During flu seasons when vaccine supplies are limited of delayed, the Advisory Commfttee on Immunization Practices (ACIP) makes recommendations regafrfing priority groups for rriccinatio . 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, Pregnant women, People 50 years of age: and older, People of any age with certain chronic medical conditions, and People who live in nursing homes and other long-term care facilities. 2, People who live with or tare 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 vacxinated), and Heafth care workers. 3. Children aged 6 months up to their 19"' birthday 4. Anyone who wants to decrease their risk of influenza. Use of the Nasal Spray Flu Vaccine Vaccination with the nasal-spry flu vaccine is an option for healthy` people 2-49 years of age who are not pregnant, even healthy persons who live with or care for those in a hig"sk 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 2 of 3 i DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION SAFER-HEALTHIER- PEOPLE' 41 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 Guiliain-Barra syndrome (GBS) within 6 weeks of getting an influenza vaccine previously. Children less than 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 yol., have questions about whether you should gel a flu vaccine, consult your health-care provider. For rno, a about preventing the flu, see the following: Key Fads About Seasonal Flu Vaccine Influenza Antiviral Druos 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.govlflu, or calf CDC at 800-CDC-INFO (English and Spanish) or BBB-232-6348 (TTY), Page 3 of 3 DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL ANn PREVENTION SAFER- HEALTHIER- PEOPLE'' I I 42 PNEUMOCOCCAL VAC C I N E POLYSACCHARIDE 1 AT YOU NE ED TO KNOW) Mary VtiWm! Mf=Man 9atenlents a availabb in Spanish"other lanpwges. Se= wr jnm rhe.aWp ) ;Why get vacciriated? - _ 3 Who should get PPV? __ Pncumococcal disease is a serious disease that • All adults 65 years of age or older- causes much sickness and death. In fact, pneumococcal disease kiln more people in the • Anyone over 2 years of age who has a long- IJnited States each year than all other vaccine- term health problem such as: preventable diseases combined. Anyone can get - heart disease pneumococcal 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, RW - cirrhosis ink-crion, or certain types of canccr. - leaks of cerebrospinal fluid Pacumococcal disease can lead to serious infections of the lungs (pneumonia), the blood (bacteremia), and the covering of the brain (meningitis). About I out of every 20 people who get pneumococcal pneumonia dies from it, as do about 2 people out of 10 wbo get bacteremia and 3 people out of 10 who get meningitis. People with the special health problem:, 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 pneumococra: infections more difficult. This makes prevention of the disease through vaccination even more important. Pneumococcal 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 - ccrtaia cancer drugs - radiation therapy • Alaskan Datives and certain Native American populations. Polysaccharude Pneumococcal1 C- -- 43 t 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 cancer, leukemia, lymphoma, multiple mycloma have kidney failure have nephrotic syndrome have had an organ or bone marrow transplant are taking medication th2,t lowers immunity (nich 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 first dose. Cj? ?facts ut getting the • Otherwise hea lthy children who often get ear 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 pncumococcal 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 pricumococcal disease should be vaccinated before bccoming pregnant, if possible. Less than 1`Yo develop a fever, muscle aches, cr 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. What if there is a serious 7 reaction? What should 1 look for? • Severe allergic reaction (hives, difficulty breathing, shock). What should I do? • Call a doctor, or get the person to a doctor right away. • Tell 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-g00-822-7967. VAERS does not provide medical advice. $ How can I learn more? - Ask your doctor or nurse. They can give you the vaccine package insert or suggest other sources of information. - Call your local or state health departmenu - Contact the Centers for Disease Control and Prevention (CDC): Call 1-800-232-4636 (1400-CDC-INFO) or Visit the National Immunization Program website at www.cdc.gov/vaccines C What are the r°lsks from PPV? i ;` J F PPV is a very safe vaccine. , DL'PARTME19T OF HEALTH ALO MUMAfi SE7lVittLtC About half of those who get the vaccine have very mild CL•NTe RS FOR DISEASE CONTROL AND PREVENT,ON side affects, such as xedness or pain where the shot is _ given. Pneumococral ` Vaccine Information Statement \'. 44 42?? CWIRCH OF GOD NOME 'Committed 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. 011herwise, 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. 7 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. 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. I have received literature pertaining to the benefits of the Pneumococcal Pneumonia Vaccine. It known, please indicate the date when the vaccines listed below were last received. Tri-Valent Influenza vaccine: Pneumonia Vaccine: Tetanus Vaccine: ;Date' 45 1 i`acifity Representat; 2CHURCH OF GOD NOME "Committed to Cann?" 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 ($5.00) at any one time in their possession or rooms, and keep no valuables, real or intrinsic, in their rooms. By signing this 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 have 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. Pate) 46 ResidenllResponsible Party; CHURCH OF GOD HOME, INC. ADMISSION AND CARE AGREEMENT THIS AGREEMENT is made on this _ 0 day of A , 20L!2, by and between the Church of God Home, Inc., called the "Facility," a Pennsylvania n n-profit corporate loc d at 80 North Hanover Street, Carlisle, umbland County , nnsyl ania, and called "Resident" and, % call esponsible Party" 1 The Resident and the Responsible Party reaffirm th a 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: PROVISION OF SERVICES - The Facility will provide Resident with: a. Skilled nursing can:, 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 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: 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 No interest will be paid on the security deposit. A security deposit will not be charged to residents 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 Assisted Living, 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. 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 properly 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 rate/charge. ADMISSION - The Resident will be admitted, or a bed will be reserved for Resident, beginning on _ 3 _30' 10 . 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. d. 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. e. Pharmacy changes will be billed as a separate part of the Facility's monthly bill, and will require a separate check. `. Outside providers will bill directly and separately. 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. "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) 101. 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 Resident's bed will be reserved and changes for the reserved bed will continue to accrue unless the Resident or Responsible Party otherwise directs in writing. 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 Ibed 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 do not wish to hold a bed in the event of a hospitalization. I understand that by doing r° ?Tci o, the bed may no be available for readmission. V be determined at time of hospitalization. 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 rnad?. 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 departureJtransfeddischarge 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: i. The transfer or discharge is necessary to meet the Resident's welfare which cannot be bet 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 cr 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 riot 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 endorse and turn over to the Facility any payments received from third-parties to the extent necessarlr 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 facility 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 nametag labels are needed for clothing items, 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 s FAd,mnission ;and Care Agreement- continued I 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. (bale) esidenVResponsible Partyl 52 II _, RESIDENT I FAMILY GUIDE TO INQUIRIES AND INFORMATION 0 } 0 C m C%) E CF, r- r FA 0 Inquires N Q V d cc (? 0 L Y V O a ? cu L u O w .? I en E v Z a V 2 N O -0 a W t 3:W * m0 t 0 0 1E LL.0 2 to 0? d j ?a? 7 lU zc1 d O Q1 wza co co >0 -- Healthcare ----- - - - Personal Care X Admissions Independent Living X Admission - i Billing Question x --- ------- X - Question Applying for ------ X Medicaid - Pharmacy Billing X Laundry Billing X Donation Monetary x Dtmation Other - X Personal Cash Account X Questions Personal Cash _ ?- Deposits J X Withdrawals ? -? Guest Meal Reservations X ---- - - -- - - --- --- - - + -+--- Part y Reserving of Lounge - X - Family Concems X HIPIPA Changes X Coordinate Change in Level of Care X Resident Lost Items X t Tele hone Cabile j { X Hook-up -- - -_ _ Y- - - --- Lel ort X. Guest Suite - 53 RESIDENT 1 FAMILY GUIDE TO INQUIRIES AND INFORMATION i i? j i I c N ? ry m ? y 0 'D c rn ? 0 ? C N ? r- N `¢ C tom! d 0 L X as 0 O 0 A to .C is C] = U Inquires < _E :r 0) Imo U L- C U- 0m °' z0 d 0-0 0 w M?¢ I Wtn c I » Change in Laundry- i Service i x Transport Requests ---- - - X x Special Hair Care - --- ---- - Requests, Payment: Scheduling - X Resident Care -- ---- ---i ', Resident Medication ? I Physician Questions i X { -- ---? ---------- ?--- Therapy Questions -- - X Taking Residents Out of Facility -- X Change in POA - - -- - Contact X Address /Phone Change in POA --- - --- ---- - _ X i Health Insurance - --- 4- - - Canis X Religious Questions i X Funeral Questions i _ X ? Funeral Processio111 - ^- ' - j Service ? X ; _.._ Mern6nal Services -- ------ X "The Orchards" at i I - ----I -- --- Marsh Run ? X 54 i i ^ e jjr f Facility Mailing Address: 801 North Hanover Street Carlisle, PA. 17013 W91 VIL Facili Main Telephone #: (717) 249-5322 Facility Administrator: .................... Susan Bower, NHA ............................................................. ext. 3086 Y Y Y Y Y Y dal V? Y Y N Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y Y --------- Y Y Y Y Y ----------------- Activity De-t.: Business Office: care Plan: Chap air Dietary: Hair Care_ Medical Appts.: Nursing Dept: Pharmacy;- Social Services: Therapy Dot.: ? ..............Amy Findon, CTRS..... ,................ ............ ...........................ext. 3021 (Director of Activities) -?, ............. Sharon Cramer (Business Office / Henderson House) ...... ...... ..........ext. 30? (Sr. Billing AIR Specialist - Personal Cash Accounts) .............. Michele Shughart (Business Office / Henderson House) .... .... ........ ..ext. 3095'- j-Assistance) (Billing Specialist - Medi o , .............. Lynne Shellenberger, RN (Mtg. wAn 14 days of Admissrn?.. ext. 3Q 3333 (Nursing Assessment Coordinator - RNAC) ?- -- ? .............. Pastor Bradley Moore........................................................... ext. 3022 ....... Bradley Weiser ..................................................................... ext. 3022 (Director of Dining Services) ? ............. Joan Ludwig ........................................................................... ext. 3003 (Director of Hair Care) ? ............. Jessica Dietz ........................................... ............. ................. ext. 3961 (Nursing Administrative Assistant) ? .............. Mary Hartman, RN, BSN ..................................................... ext. 3015 (Director of Nursing) ? .............. Faith Long Hall (#103-116) ....................... ......... , ...... .... ext. 3009 .............. Faith Short Hall (#99,100-102,117-126) ,. try... .., ext. 3(l (#201-215) ............................................. ... ........ .. . . ..... .. ext. 3024 Love) ? ..............Love l1(#217-239).... ........... ................. ............ ....... ...•--- ..ext. 3025 ? .............. Chris Ward, LPN.............................. . ext. 3012 (Person Care Administrator), (Hope, Peace and Creekside Apt.) ? .............. Continuing Care RX.................... ............... .... .......1-800-675-2279 .............. Erin Naylor, MSW...... ,................ . (Director of Social Services) ? ..............Ellen Myers, BSW...... ................. . (Social Worker) ] .............. Genesis Rehabilitation Services. . Volunteer Office: ? ..............Linda Waggoner.... r'- i rE (Director of?Volunteers) t Physician 55 ...... ................... e . 3084 ) -___ ..................................... ext. 3023 ................................. ?'. ext. 3017 ` ext. 3028 Telephon _ rr?=? f F.'XHIBIT "C" (TO COMPLAINT) RESIDENT STATEMENT FROM CHURCH OF GOD HOME, INC 801 N HANOVER STREET CARLISLE, PA 17013 717-248-5322 Statement Date Due Date ACCOUNT NUMBER 04/30/2012 Upon Receipt 803010 .39 AMOUNT PAID $ JEAN E HOCKENBERRY c/o BARBARA PUGH 5470 UNION DEPOSIT ROAD HARRISBURG, PA 17111 Comments $9,858.00 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. $13,767.61 $8,122.00 $10,172.27 $1,400.51 $43,320.39 e rv± a ARP yrRen s ?" 8d[ance _ Balance Forward $27,930.64 $27,930.64 02101/12 - 02/12/12 Room & Board (12) $(318.00) $(3,816.00) $24,114.64 02/01/12 - 02/29/12 Room & Board 29 $318.00 $9,222.00 $33,336.64 02113/12 - 02129/12 Room & Board (17) $(262.00) $(4,454.00;1 $28,882-64 03/01/12- 03/31112 Room & Board (31) $(262.00) $(8,122.00) $20,760.64 03101112- 03/31112 Room & Board 31 $318.00 $9,858.00 $30,618.64 04101/12 - 04130112 Room & Board (30) $(26200) $(7,860.00; $22,758.64 04/01112 - 04/30/12 Room & Board 30 $318.00 $9,540.00 $32,298.64 04/03/12 -.04103/12 Pullups - Large 1 $15.38 $15.38 $32,314.02 04/08/12 -,54108/12 Pullups - Large 1 $15.38 $15.38 $32,329.40 04/14112 - 04/14112 Pullups - Xtra Large 1 $15.07 $15.07 $32,344.47 44117112 - 44117/12 Pullups - Large 1 $15.38 $15.38 $32,359.85 04123112 - 44123/12 Pullups - Large 1 $15.38 $15.38 $32,375.23 04/28/12 - 04128/12 Pullups - Large 1 $15.38 $15.38 $32,390.61 04/30/12 - 04130112 Telephone Basic Charges 1 $30.60 $30.60 $32,421.21 04130112 - 04/30/12 Oxygen Cyclinders 11 $12.00 $132.00 $32,553.21 04130/12 - 04130112 Oxygen Contractor/ 30 days 1 $90.00 $90.00 $32,643.21 04130112 - 04/30112 Pharmacy 1 $732.72 $732.72 $33,375.93 04/30/12 - (Pt/30/12 Pharmacy OTC 1 $86.46 $86.46 $33,462.39 05/01/12 - 05/31/12 Room & Board 31 $318,00 $9,858.00 $43,320.39 TOTAL BALANCE DUE: $43,320.39 FACILITY NAME _ RESIDENT NAME ACCOUNT NUMBER L CHURCH OF GOD HOME, INC^ JEAN E HOCKEN13ERRY 803010 i? CERTIFICATE OF SERVICE { hereby certify that a true and correct copy of the foregoing P,-tition for Preliminary laiiinctioa will be forwarded to a local process server to be served simultaneously with the ?'onrirlaint ,,it the following addresses: Jean Hockenberry c/o Church of God Home, Inc. 801 North Hanover Street Carlisle, PA 17013 Barbara Pugh 5470 Union Deposit Road Harrisburg PA 17111 x Dated: i By: , Jane le Valore, Paralegal W IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA. CHURCH OF GOD HOME, INC., PLAINTIFF, VS. JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, DEFENDANTS. CIVIL ACTION- EQUITY DOCKET NO.: /aZ - 3-987 vi l rm 01. PRELIMINARY ORDER AND NOW, this , day of , 2012, in consideration of Church of God's Petition for Preliminary Injunction, it is ordered that a hearing is set for the Z` ST day of 2012, at '?>-000 -&a.ip.m. in Courtroom No. 4TH , in the Cumberland County Courthouse, Carlisle, Pennsylvania. BY THE COI JRT* ka n ki.ocket,-bell?y aarha,-A pJ-J??n?ltt VlllL?/C PQ f4 tei IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CHURCH OF GOD HOME, INC. PLAINTIFF, VS. . JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually DEFENDANTS. CIVIL ACTION- EQUITY .:, 1- 3 r-; DOCKET NO.: 12-3587 -7n ., _ F ri STIPULATION FOR ENTRY OF INDUCTION AND NOW COMES, Plaintiff, Church of God Home, Inc. ("Plaintiff' or "Church of God"), by and through its attorneys, SCHUTJER BOGAR, and Jean Hockenberry, by and through her Agent, Barbara Pugh, and Barbara Pugh, individually (collectively "Defendants"), and hereby stipulate and agree to the following: 1. On or about June 8, 2012, Church of God filed a Complaint, Petition for Preliminary Injunction and Brief in Support of Petition for Preliminary Injunction (collectively the "Litigation") against Defendants. 2. The Litigation sets forth claims against Defendants relating to their failure to timely qualify Defendant Jean Hockenberry for Medical Assistance benefits and the consequences of said failures to act. 3. A Hearing on Church of God's Petition for Preliminary Injunction in this matter is currently scheduled for June 21, 2012. 4. The parties agree to the entry of an Order directing as follows: A. Defendants shall immediately and fully cooperate with Church of God's efforts and take any and all actions necessary to insure Defendant Jean Hockenberry's complete eligibility for Medical Assistance, including but not limited to: i. Immediate turnover of all of Defendant Hockenberry's past due monthly patient pay liability to Church of God; including but not limited to Defendant Hockenberry's Social Security, pensions and/or annuities; ii. Timely and complete turnover over of all of Defendant Hockenberry's future monthly patient pay liability to Church of God within five (5) days of receipt of said income; and iii. Immediately take any and all steps necessary to directly deposit with Church of God, either electronically or by paper check, Defendant Hockenberry's monthly income. The direct deposit of Defendant Hockenberry's monthly income shall continue for as long as Defendant Hockenberry is a resident of Church of God's skilled nursing facility. B. Defendants shall timely and completely accommodate any other requests made by the Huntingdon County Assistance Office or as required by the Medical Assistance regulations to maintain Defendant Jean Hockenberry's eligibility for Medical Assistance within five (5) days of written notice by Church of God and/or the Huntingdon County Assistance Office; and C. Defendants shall immediately ensure that Defendant Jean Hockenberry's resources are, and remain, at all times, within the resource limitations required by the Medical Assistance regulations. 5. The Parties further agree that failure to abide by the terms of this Stipulation for Entry of Injunction may constitute contempt and may result in sanctions, including the payment of attorney's fees. 6. The Parties hereby request this Court accept and adopt this Stipulation for Entry of Injunction directing its implementation. 7. Upon the Court's acceptance and adoption of this Stipulation for Entry of Injunction, the hearing currently scheduled for June 21, 2012 will no longer be necessary. Respectfully submitted, SCHUTJER BOGAR Dated: 01-- By: Nana 661 Esq. PA orney I.D. No.: 311922 309 Fellowship Road, Suite 200 Mt. Laurel, NJ 08054 Phone: (856) 533-2464 Fax: (856) 533-2461 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 Attorneys for Church of God Home Inc. Dated: By: Dated. IN THE COURT OF COMMON PLEAS OF '11C? i;ft CUMBERLAND COUNTY, J071 2 P1 CHURCH OF GOD HOME, INC. PLAINTIFF, F'c tRISYLVA,,m CIVIL ACTION- EQUITY VS. JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually DEFENDANTS. DOCKET NO.: 12-3587 ORDER Y ST AND NOW, this r?-t, day of June 2012, in consideration of Church of God's Petition for Preliminary Injunction and the parties' Stipulation for Entry of Injunction: It is hereby ORDERED AND DECREED that: 1. Church of God's Petition for Preliminary Injunction is granted; 2. The parties' Stipulation for Entry of Injunction is adopted; 3. Defendants shall immediately and fully cooperate with Church of God's efforts and take any and all actions necessary to insure Defendant Jean Hockenberry's complete eligibility for Medical Assistance, including but not limited to: a. Immediate turnover of all of Defendant Hockenberry's past due monthly patient pay liability to Church of God; including but not limited to Defendant Hockenberry's Social Security, pensions and/or annuities; b. Timely and complete turnover over of all of Defendant Hockenberry's future monthly patient pay liability to Church of God within five (5) days of receipt of said income; and c. Immediately take any and all steps necessary to directly deposit with Church of God, either electronically or by paper check, Defendant Hockenberry's monthly income. The direct deposit of Defendant Hockenberry's monthly income shall continue for as long as Defendant Hockenberry is a resident of Church of God's skilled nursing facility. 4. Defendants shall timely and completely accommodate any other requests made by the Huntingdon County Assistance Office or as required by the Medical Assistance regulations to maintain Defendant Jean Hockenberry's eligibility for Medical Assistance within five (S) days of written notice by Church of God and/or the Huntingdon County Nssistance Office; and 5. Defendants shall immediately ensure that Defendant Jean Hockenberry's resources are, and remain, at all times, within the resource limitations required by the Medical Assistance regulations. Failure to abide by the terms of this Order may constitute contempt and may result in sanctions, including the payment of attorney's fees. The hearing scheduled for June 21, 2012 is hereby canceled. BY THF, COURT: T Honorable aarbQ p,4 A ? ? IJCcrt? (?'ru i t"?` mss` 6W5 YinaJed - -.-I- + f1. I lalorzy IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 12-3587 AFFIDAVIT OF SERVICE Church of God Home, Inc. vs. t^Y Jean Hockenberry, by and a s '"i through her Agent, Barbara and Barbara Pu h P h r g , , ug i di id ll Cra C> 1 n v ua y Co=onwealth of Pennsylvania OC3 County of Dauphin sS. 7 depose and say that at 12:10 P0 being duly sworn according to law etent adult Casin Shunk a com I one . . , , , p , 06/18/2012, I served Barbara Pugh at 5470 Union Deposit Road, Harrisburg, PA 17111 hi fhe manner described below: ® Defendant(s) personally served. ? Adult family member with whom said Defendant(s) reside(s). Relationship is ? Adult in charge of Defendant(s) residence who refused to give name and/or relationship. ? Manager/Clerk of place of lodging in which Defendant(s) reside(s). ? Agent or person in charge of Defendant's office or usual place of business. ? Other: an officer of said Defendant's company. a true and correct copy of Civil Covert Sheet; Notice to Defend; Complaint; Verification; Petition for Preliminary Injunction; Brief in Support of Petition for Preliminary Injunction; letter dated June 15, 2012 issued in the above captioned matter. Description: Sex: Female - Age: 58 - Skin: White - Hair: Brown - Height: 5'06" - Weight: 190 Sworn to and subscribed before me on this 40 ?? day of ZZ4P,t 20LL. ?J ;?r NOTARY BLIC COMM EALTH OF PENNSYLVANIA Notarial Seal John F. Shinkowsky, Notary Public Lower Paxton Twp., Dauphin County My Commission Expires Sept. 28, 2014 Casin Shunk Shinkowsky Investigations Post Office Box 126538 Harrisburg, PA 17112 (800) 276-0202 Atty File#: - Our File# 20316 Law Firm: Schutjer Bogar - South Carolina Address: 4000 Faber Place Drive, Suite 349, North Charleston, SC, 29405 Telephone: (843) 235-3674 FILED-OFFICE IN THE COURT OF COMMON PLEAS OIF THE PROTHONOTARY CUMBERLAND COUNTY, PENNSYLVANIA 2012 JUL I I AN 11: 5 3 CHURCH OF GOD HOME, INC., PLAINTIFF, CUMBERLAND COUNTY PENNSYLVANIA CIVIL ACTION- EQUITY VS. JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually, DEFENDANTS. DOCKET NO.: 12-3587 AFFIDAVIT OF SERVICE I, Janelle Valore, being duly sworn according to law, depose and say that I sent the annexed Order issued in the above-captioned matter to Barbara Pugh at her place of residence located at 5470 Union Deposit Road, Harrisburg, Pennsylvania 17111 on the 22nd day of June, 2012, via first-class, United States mail, postage prepaid. As of today's date, the mail as not been returned. Dated: JjA `1 b ? °? 0 0 Sworn to and Subscribed before me this day of .\k`1, i 2012. Y Valore, Paralegal NOTARIAL SEAL AMY L. MOUNTZ, Notary Public ORIGINAL Susquehanna Twwpp , Dauphin County My Comnassion ExOm January 25, 215 IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA i ?J I1? (i" ?l ? 'T I ? ??N' 111 21 PH 1: 09 ?'NI?QF?D-D-SOME,?i-G----...------?----------------- --i??1$? ?41?-_ _ PLAINTIFF, CIVIL ACTION- EQUITY VS. JEAN HOCKENBERRY, by and through her Agent, BARBARA PUGH, and BARBARA PUGH, individually DEFENDANTS. DOCKET NO.: 12-3587 ORDER sr AND NOW, this 2-1 day of June 2012, in consideration of Church of God's Petition for Preliminary Injunction and the parties' Stipulation for Entry of Injunction: It is hereby ORDERED AND DECREED that., 1. Church of God's Petition for Preliminary Injunction is granted; 2. The parties' Stipulation for Entry of Injunction is adopted; 3. Defendants shall immediately and fully cooperate with Church of God's efforts and take any and all actions necessary to insure Defendant Jean Hockenberry's complete eligibility for Medical Assistance, including but not limited to: a. Immediate turnover of all of Defendant Hockenberry's past due monthly patient pay liability to Church of God; including but npt limited to Defendant Hockenberry's Social Security, pensions and/or annuities; b. Timely and complete turnover over of all of Defendant Hockenbeny's future monthly patient pay liability to Church of God within five (5) days of receipt of said income; and c. Immediately take any and all steps necessary to. directly deposit with Church of God, either electronically or by paper check, Defendant Hockenberry's_monthl-y-.income.-----.-T-lie-d-it-eft--deposit e-f-Delendar-a-- -- -- Hockenberry's monthly income shall continue for as long as Defendant Hockenberry is a resident of Church of God's skilled nursing facility. 4, Defendants shall timely and completely accommodate any other requests made by the Huntingdon County Assistance Office or as required by the Medical Assistance regulations to maintain Defendant Jean Hockenberry's eligibility for Medical Assistance within five (5) days of written notice by Church of God and/or the Huntingdon County Assistance Office; and 5. Defendants shall immediately ensure that Defendant Jean Hockenberry's resources are, and remain, at all times, within the resource limitations required by the Medical Assistance regulations. Failure to abide by the terms of this Order may constitute contempt and may result in sanctions, including the payment of attorney's fees. The hearing scheduled for June 21, 2012 is hereby canceled. BY THE COIMj,___.. Honorable JudgL Thomas A. Placey