HomeMy WebLinkAbout12-3858IN THE COURT OF COMMON PLEAS OF }
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC., C o U ? '
Plaintiff, Docket No. a , 3 8sb?4 L.l Ui /
V.
CIVIL ACTION - LAW
RUTH AUBIN and
MICHAEL BLESS, individually and as Agent
through a Power of Attorney for RUTH AUBIN,
Defendants.
NOTICE TO DEFEND
Pursuant to Pa. R.C.P No. 1018.1
YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth
in the following pages, you must take action within twenty (20) days after their complaint and
notice are served, by entering a written appearance personally or by attorney and filing in writing
with the court your defenses or objections to the claims set forth against you. You are warned
that if you fail to do so the case may proceed without you and a judgment may be entered against
you by the court without further notice for any money claimed in the complaint or for any other
claim or relief requested by the plaintiff. You may lose money or property or other rights
important to you.
YOU SHOULD TAKE THER PAPER TO YOUR LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW.
THER OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER.
IF YOU CANNOT AFFORD TO HIRE A LAWYER, THER OFFICE MAY BE ABLE
TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER
LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, PA 17013
(717) 249-3166
Ck 4a9 7
a-7( q y3
EN LA CORTE DE ALEGATOS COMUN DEL
CONDADO DE CUMBERLAND, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff, Docket No.
V.
CIVIL ACTION - LAW
RUTH AUBIN and
MICHAEL BLESS, individually and as Agent
through a Power of Attorney for RUTH AUBIN,
Defendants.
AVISO PARA DEFENDER
Conforme a Pa. R.C.P Num. 1018.1
USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las
demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de
los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando
personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por
escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le
advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede
proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier
otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la
Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos
importantes para usted.
USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO
INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA
SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE 1NFORMACION A CERCA
DE COMO CONSEGUIR UN ABOGADO.
SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES
POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE
AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A
PERSONAS QUE CUALIFICAN.
Cumberland County Bar Association
32 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, Docket No.
V.
RUTH AUBIN and
MICHAEL BLESS, individually and as Agent
through a Power of Attorney for RUTH AUBIN,
Defendants.
COMPLAINT
CIVIL ACTION - LAW
AND NOW, comes Church of God Home, Inc. ("Church of God"), by and through its
attorneys, SCHUTJER BOGAR, and files the within Complaint against Defendants Ruth Aubin
("Defendant Aubin") and Michael Bless ("Defendant Bless"), (collectively, "Defendants"), and
in support thereof, provides as follows:
1. Church of God is a corporation created and existing under the laws of the
Commonwealth of Pennsylvania, with its principal offices located at 801 North Hanover Street,
Carlisle, Pennsylvania 17013.
2. Defendant Aubin is an adult individual who currently resides at 4837 East Trindle
Road, Mechanicsburg, Pennsylvania 17050. Defendant Aubin was a prior resident of Church of
God's skilled nursing facility located at 801 North Hanover Street, Carlisle, Pennsylvania 17013
from March 14, 2011 to October 28, 2011.
3. Defendant Bless is an adult individual who currently resides at 22 Summit Place,
Cedar Hill, Texas 75104. Defendant Bless is the son of and Agent pursuant to a Power of
Attorney for Defendant Aubin. See Power of Attorney attached hereto as Exhibit "A."
4. At the time of Defendant Aubin's admission to Church of God's skilled nursing
facility, and at all times relevant hereto, Defendant Bless was operating as Defendant Aubin's
Responsible Party and Agent under a Power of Attorney.
5. On or about March 14, 2011, Church of God and Defendants entered into a
written Nursing Care Admissions Contract ("Contract"), pursuant to which Church of God
agreed to provide Defendant Aubin with skilled nursing services in exchange for, inter alia,
Defendants' promise to pay a specific monetary fee from Defendant Aubin's resources. A true
and correct copy of the Contract is attached hereto as Exhibit "B."
6. In furtherance of the Contract, Defendants "irrevocably authorize[d] the Facility
to make claims and to take such other actions as maybe necessary... now or hereafter payable to
the extent of all charge due to the endorse and turnover to the Facility any payments received
from third parties to the extent necessary to satiety the charges under this Agreement." See page
51 of Exhibit "B."
7. In addition, Defendant Michael Bless agreed, as Responsible Party, to "pay all
fees and costs from Resident's resources." See Id. at page 49.
8. After Defendant Aubin was admitted to Church of God's skilled nursing facility,
she allegedly became insolvent and her bills for skilled nursing care went unpaid.
9. As a result, Church of God filed an application for Medical Assistance benefits on
Defendant Aubin's behalf with the Cumberland County Assistance office ("CAO") on or about
July, 2011.
10. Defendant Aubin was discharged from Church of God's skilled nursing facility on
or about October 28, 2011.
2
11. On March 14, 2012, the CAO approved Defendant Aubin for Medical Assistance
benefits, effective July 1, 2011; however, as a condition of continued Medical Assistance
eligibility, Defendants are required by Medical Assistance regulations to pay Defendant Aubin's
available monthly income to Church of God. See 55 Pa. Code § 181.452-53. A true and correct
copy of the PA-162 dated March 14, 2012 is attached hereto as Exhibit "C."
12. Specifically, the CAO determined Defendant Aubin's monthly patient pay
liability to be Three Thousand Two Hundred Eighty-Seven and 501100 ($3,287.50) Dollars for
the months of July, 2011 through the date of her discharge on or about October 28, 2011. See
Exhibit "C."
13. In accordance with the Contract, Church of God provided room, board and skilled
nursing services to Defendant Aubin from approximately March 14, 2011 through the date of her
discharge on or about October 28, 2011.
14. However, in violation of the applicable Medical Assistance regulations and the
Contract entered into with Church of God, Defendants failed to turnover Defendant Aubin's
patient pay liability to Church of God.
15. As a result of Defendants' breach of their contractual obligations and in violation
of the applicable Medical Assistance regulations, by failing to turn over Defendant Aubin's
patient pay liability from July 1, 2011 through October 28, 2011, an outstanding balance of
Twelve Thousand Nine Hundred Sixty-Seven and 80/100 ($12,967.80) Dollars is owed to
Church of God for the skilled nursing services it provided to Defendant Aubin. A true and
correct copy of the Invoice is attached hereto as Exhibit "D."
3
COUNTI
BREACH OF CONTRACT/MONETARY DAMAGES
Plaintiff v. Defendants
16. The allegations contained in Paragraphs 1 through 15 are incorporated by
reference as though restated in full.
17. Pursuant to the Contract entered into with Church of God, inter alia, Defendants
are contractually obligated to cooperate fully with the Medical Assistance determination process
and to turn over Defendant Aubin's monthly patient pay liability. See Exhibit "B."
18. Church of God provided skilled nursing care and services to Defendant
Aubin from approximately March 14, 2011 until October 28, 2011 in accordance with the terms
and conditions of the Contract.
19. Defendants have breached the Contract by failing to make payment from
Defendant Aubin's patient pay liability to Church of God for skilled nursing services rendered to
Defendant Aubin.
20. As a direct result of Defendants' breach of their contractual duties under the
Contract, Church of God has incurred damages totaling Twelve Thousand Nine Hundred Sixty-
Seven and 80/100 ($12,967.80) Dollars plus attorney's fees and costs. See Exhibit "D."
COUNT II
BREACH OF STATUTORY DUTY OF SUPPORT/ MONETARY DAMAGES
Plaintiff v. Defendant Bless
21. The allegations contained in Paragraphs 1 through 20 are incorporated herein by
reference as if fully set forth at length.
22. Defendant Bless is the son of Defendant Aubin.
23. At all times material hereto, Defendant Bless has had a duty to support his
mother, Defendant Aubin. See 23 Pa.C.S. § 4603.
4
24. Church of God provided care and services to Defendant Bless's mother, who,
upon information and belief, at all times material hereto, has been indigent and unable to
compensate Church of God for the care and services it provided to her.
25. Upon information and belief, at all times material hereto, Defendant Bless
possesses sufficient financial means to assist his mother, Defendant Aubin, in paying for the care
and services that Church of God provided to her.
26. At all times material hereto, Defendant Bless has failed to financially support his
mother.
27. As a result of the failure of Defendant Bless to provide financial support for his
mother, Church of God has incurred damages in the amount of Twelve Thousand Nine Hundred
Sixty-Seven and 80/100 ($12,967.80) Dollars plus attorney's fees and costs. See Exhibit "D."
WHEREFORE, Church of God respectfully requests that this Court enter a judgment
against Defendants in the amount of Twelve Thousand Nine Hundred Sixty-Seven and 80/100
($12,967.80) Dollars, plus interest, costs, and attorney's fees, and grant such other and further
relief as the Court deems necessary and just.
[Remainder of Page Intentionally Left Blank]
5
Respectfully submitted,
Dated: (t, 4 /,j 0 Lk
SCHUTJE GAR
By:
Kirk . Sohonage, Esquire 037
PA Attorney I.D. No.: 77851
1426 N. 3rd Street, Suite 200
Harrisburg, PA 17102
Phone: (717) 909-8160
Fax: (717) 909-5925
Ivana Grujic, Esquire
PA Attorney I.D. No.: 311922
309 Fellowship Road, Suite 200
Mt. Laurel, NJ 08054
Phone: (856) 533-2464
Fax: (856) 533-2461
Attorneys for Church of God Home, Inc.
6
VERIFICATION
The undersigned hereby verifies that the statements of fact in the foregoing Complaint
are true and correct to the best of my knowledge, information and belief. I understand that any
false statements therein are subject to the penalties contained in 18 Pa. C.S.A. § 4904, relating to
unsworn falsification to authorities.
Dated: z 2L'?it- ?? ? (ZLAt%YI
Karen Stephenson, Representative of
Church of God Home, Inc. Ob-1-
?>
EXHIBIT "A"
(TO COMPLAINT)
ADVANCE HEALTH CARE DECLARATION (LIVING WILL)
AND HEALTH CARE ROWER OF ATTORNEY
OF
RUTH AUBIN
1, RUTH AUBIN, of 130 Tower Circle, Carlisle, Cumberland County, Pennsylvania,
being of sound mind, willfully and voluntarily make this declaration to be followed if I
become incompetent or unable to express myself.
This declaration reflects my commitment to refuse life-sustaining treatment if I have
a terminal or end-stage medical condition or am in a state of permanent unconsciousness,
including a persistent vegetative state or irreversible coma.
If I am in such condition or state, I direct my attending physician(s) to withhold or
withdraw life-sustaining treatment that serves only to prolong the process of my dying, and
that treatment be limited to measures to keep me comfortable and to relieve pain, including
any pain that might result from the withholding or withdrawal of life-sustaining treatment,
even if such measures may hasten the moment of my death.
Furthermore, if I am ever in such condition or state, I leave the following directions
l?W?i &
I. ?SAY
'6 Win f*0 Sum
Ca ask. PA
concerning my medical treatment:
I do I do not
[ ) [>e] want cardiac resuscitation.
[ ) [,?{ want mechanical respiration.
[ ) pe) want tube feeding or any other artificial or invasive form of
nutrition.
I do I do not
( J (: J want hydration (water) as may be necessary for my comfort.
{ J {?J want blood or blood products.
(J want any form of surgery or invasive diagnostic tests.
want kidney dialysis.
(J (J want antibiotics or medication other than pain-relieving
medication.
( ] want chemotherapy.
1 realize that if 1 do not specify my preference regarding any of the forms of
treatment listed above, I may receive that form of treatment.
I designate the following person as my health care agent to make medical treatment
decisions for me if I should become incompetent or unable to express myself, whethel. or
not f have a terminal or end-stage medical condition or am in a state of permanent
unconsciousness-
Name and address of health care agents:
Name: David G. Au in 1 }? 1
Address: t0633 Tdo, io y3 61-5' Sit, POA
Home Phone:
and
Name: Michael R. Bless
Address:
SAII)IS,
JCFVVER &
LINDSAY
5 VM High Sum
C-2disk. PA
Dallas and Commerce, Texas
Home Phone:
?fy - -x.30- 5.,.?
My health care agent or substitute agents appointed hereunder shall have those of
the following powers marked "Yes," subject to my directions in this Combined Living Will
and Health Care Power of Attorney:
2
i
Yes No
1. To authorize my admission to, or discharge from, a
medical, nursing, residential, or similar facility and to enter
into agreements for my care.
[, [ ) 2. To access, and to authorize others to access, any and all
medical information and records of mine and/or about me; as
my Personal Representative under the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), to receive
my protected health information and to authorize the disclosure
and use of my protected health information as provided in 45
CFR Part 164.
[ ) 3. To employ and discharge medical and related personnel.
(}Q ( ] 4. To authorize medication, surgical procedures, and/or other
medical care for curative purposes, for treatment of specific
symptoms, and to relieve pain. If I am suffering under a
terminal condition from which I cannot recover, in the opinion
of my attending physician, I specifically recognize and accept
that an authorized medication and procedure to relieve pain
or a spec symptom may accelerate my death.
' ( ) 5. To complete insurance, admission, and other
health-related forms, applications, certifications, and
documentation.
j 6. To grant releases to health care professionals or
institutions.
[?' [ ] 7. To authorize the donation of my anatomical parts.
[ [ ) 8. Any power herein to authorize an action shall also be
deemed to be a power to deny or withhold authorization of
speck acts.
SA,IIJIS,
LOWER 9. Subjecf to any substitutes named herein, to appoint
MOW successor or substitute health care agents hereunder.
6 Wet High Street
Carlisle. PA I hereby approve, ratify, and confirm any action taken by my said health care agent
and substitute agent(s) appointed hereunder, until this Declaration is duly revoked under
my hand and seal. This Combined Living Will and Health Care Power of Attorney and grant
3
of powers thereunder to my health care agent and substitute agent(s) shall not be affected
by my disability, incapacity, incompetency, or by uncertainty as to whether I am dead or
alive.
I have signed this Declaration on this 15` day a! April, 2008.
Declarant's signature:
Ruth Aubin '-
Declarant's address: 130 Tower Circle
Carlisle, PA 17013
The Declarant knowingly and voluntarily signed this writing by signature or mark in
our presence.
Witness's signatu : f '
Witness's address: 26 West High Street
Carlisle, PA 17013
Witness's signature: fit: (r
Witness's address: 26 est High Street
Carlisle, PA '17013
AWMt &
LMS"
W= H* Sam
Cul4k, PA
4
?IAR. I a. 20 11 11:12AM NO. 7636 P. 2/6
GENERAL PAD E F TT gY
0 CE
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON
YOU DESIGNATE (YOUR 'AGENTA) BROAD POWERS TO HANDLE YOUR
PROPERTY, WHICH MAY INCLUDE POWERS TO BELL OR OTHERWISE
DISPOSE OF ANY REAL OR PERSONAL PROPERTY WITHOUT ADVANCE
NOTICE TO YOU OR APPROVAL By YOU.
THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR
AGENT To EXERCISE GRANTED POWERS, BUT WHEN POWERS ARE
EXERCISED. YOUR AGENT MUST USE DUE CARE TO ACT FOR YOUR BENEFIT
AND IN ACCORDANCE WITH THIS POWER OF ATTORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT
YOUR LIFETIME, EVEN AFTER YOU BECOME INCAPACrrATED, UNLESS YOU
EXPRESSLY LIMIT THE DURATION OF THESE POWERS OR YOU REVOKE
THESE POWERS OR A COURT ACTING ON YOUR BEHALF TERMINATES YOUR
AGENT'S AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR
AGENT'S FUNDS.
A COURT CAN TAKE AWAY THE POWER OF YOUR AGENT IF IT FINDS
YOUR AGENT IS NOT ACTING PROPERLY. .
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF
ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH.56.
IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO
EXPLAIN IT TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I
UNDERSTAND ITS CONTENTS.
MY ATTORNEYS, SAIDIS. FLOWER & LINDSAY, HAVE EXPLAINED THIS
NOTICE AND THE POWER OF ATTORNEY TO ME, I HAVE HAD THE
OPPORTUNITY TO ASK QUESTIONS AND I UNDERSTAND THE CONTENTS OF
THESE DOCUMENTS.
Date Ruth Aub , P'rlnclpal
MAR, 11, 20 11 11:12AM
POWER Qf ATTORNEY
NO, 7636 P. 3/6
1, Ruth Arbin of North Middleton Township, Cumberland County, Pennsylvania
('Pdnclpaf'7, hereby appoint Michel R. Bless of 22 Summit Place, Cedar Hill, Texas
(hereinafter referred to as Iny Agw#7 my Agent. My Agent shall have full power of
substitution, for me and in my name, to transact ail business and to manage ail my
property and afFalra as I might do tf personally present.
I. SPwIfication of Powers
In addition to the above general powers, my Agent and my Successor Agent shall
have the following specific powers:
(1) To make limited gft of my property, In equal amounts, to my issue,
including my Agent.
(2) To create a trust for my benefit.
(3) To make additions to an existing trust for my benefit.
(4) To claim an elective share of the estate of my deceased spouse.
(5) To disclaim any Interest In property.
(6) To renounce fiduciary positions.
(7) To withdrew and receive the Income or corpus of a trust
(8) To authorize my admission to a medical, nursing, residential or similar
facliky and to enter Into agreements for my care.
(9) To authorize medical and surgical procedures.
(10) To engage in real property transactions.
(11) To engage In tangible personal property transactions.
(12) To engage In stock, bond and other securities transaction.
(13) To engage in banking and financial transactions.
(14) To borrow money.
2
MA'k 18. 2011 11:12AM
(15) To enter safe deWsit boxes.
(16) To engage in Insurance transactions.
(17) TO engage In retirement plan transactions.
(18) To handle Interest in estates and trusts.
(18) To pursue claims and litigation.
(20) To receive government benefits.
(21) To pursue tax matters.
(22) To make an anatomical gift of all or part of my body.
N0.7636 P. 4/6
IL WAn9k. For to purposes of this Power, a [Otter from, a dui Qcensed
phY$Idsn stating that after ommihallvn an Agent named herein is r auy or
physically lncapadfated, as such that he or she would be unable to act as my Agent,
shall be conclusive proof of such AgWo sp y,
ill. Durable P mw of ptto?_____t?hav, This Is a durable power of atwmsy and It shag not
be affected by my subsequent disabli ty or incepecky. Ail acts done by my Agent
pursuant t0 this power shall have the same effort and shall Inure to my benefit and
bind me and my successors In Interest as It I were competent and not disabled.
IV. RaffirAlon. I' hereby ratify and confirm all that my Agent or my successor
Agents shag lswfulr do or cause to be done by virtue hereof.
V. Gana This power of ettOmey shall be Constructed by and
Interpreted in accordance with the laws of the Commonwealth of Pennsylvania.
IN WITNESS WHEREOF, I have hereunto set my hand and seal on this, the
250 day of May, 2010.
WITNESS:
AAAA
Ruth Au n, Prindpai
3
-VIXR,18. 2011 11:13AM
NO, 7636 F. 5/6
COMMONWEALTH OF PENNSYLVANIA )
COUNTY OF CUMBERLAND : as.
)
On this, the 26e day of May, 2010, before me, a notary pubff% the under*ned
offer, person* appeared Ruth Aubin known to me (or svftfactortty prom) to be
the person whose name Is subsoibed to the within Power of Attorney, and
acknowledged that she executed the same for the purpose therein oontoed.
IN WITNESS WHEREOF, I have hereurft set my hand and official neat.
t7
Notary Public
neti
4
MA?t, 1 , 2011 1i:13RM NO. 7636 P. 6/6
ACKNOWLEGMENT BY AGENT AND SUCCESSOR AGENT
I, Michael R. Bless, have read the attached Power of Attorney and am the
person Identifl®d as the Agent for the pdnclpai. i hereby acknowledge that in the
absence of a specific provision to the contrary in the power of attorney or In 20 Pe.C.S,
when i act as agent.
I shall exerdse the powers for the benefit of the principal.
I shall kdep the assets of the principal separate ftom my assets.
I shall keep a full and accurate record of all actions, receipts and disbursements
on behalf of the principal.
--- 0 /-'; 5 /- /
5
EXHIBIT "B"
(TO COMPLAINT)
42!b?
CHURCH
OF GOD
HOME
`Committed to Caring"
Nursing Care
Admissions Contract
Information
i
Church of Cod Home, InC.
801 N. Hanover Street • Cadizle, PA 17013
P: (717) 249-5322 - F: (717) 249-8622
Revised 01l2011
?. ya
CHURCH
OF GOD
NOME
"Commitrrd to Curing"
Gear Friend:
Admission into a he care facility is a learning experience, both for the new resident and their family. We
at the Church of Gad Hones try t0 make the admission process n posit m, pleasant al easy as possible.
Because of thi amber of docuniants that must be explained and signed upon admission, many facilities
lock at this as being 'oven yhelming However, both State and Federal regulations require such forms for
Perm t records.
As we welcomes Tie new resident, a hard is ex an ded in ri-ndship...an arm offiared fforr sum... a
cheerful pat of encouragement is given... thess are a few of the special tobd'Fs that the Citurch of God
Home has been offering sine its doors first open in 1°48.
For mm ft n zbq. years a Christion spirit lhas been the qudng Oilosophy of our Home. TWs the
reason our care goes far heyond just meeting tiie physical n-rls of our residents.
We believe in ii?e d?n+iy and segi-walh of each individual, and every aspect of our care mfg M beef.
Our mission is to minister to the physical, spiritual, and ernotionnl need of each resident in order to help him
or her lead a me meaningful iife.
In sharing tip v s; standards of the Church cf God Home, we hope That our Wedence bereft
others so ti at, t?? , we wig continue to find better ways to serve a needs of elderly people in our
society.
44
Can G. Ritdile, CPA, fIHA
PresidenttCE0
2
Table of Contents
1. 'Nelcome Leiter ..........................................................................................................................2
2. Statement of Vision and Mission .................................................................................... .............4
3. Ambulance ...................................................... ............................................... ,............... ............. 4
4. Chart of Costs ..........................,..................................................................................... ......... 5-7
5. Dietary Services .. ..... ............................................................................................ ......... 7-13
6. DVD "A Time of Transition" .. ...................................................................................... .............8
7. Guest Room .................................................................................................................. .............8
8. America's Best Medical .... .......................................................................................... .............9
9. Medicaid (Medical Assistar )... ................................................................................... ....... 9-10
10. Medicaid (Medical Assis:ar ) Residents ... ...... .................................................... ...........11
11. Medicaid (Madicat Assistance) Residents Ched&t .......... ........................................ .....12-13
12. Medicare ................................................................................... .....14-15
13. Mobile X-Ray Imaging, Inc ............ .............................................................................. ...........16
U. Psychiatrist .............................................................................................................. ...........16
{ 15 Smoke Free EnvkonmW .. . ................................................................................. ...........17
.
16. Specialized Services .......... ...................................................................................... ...........17
17. Transportation .................... ....., .............................................................................. ...........17
18. Undamtandirg Restraint Use ....................................................................................... ...........18
19. Advance Directive Policy .... ...................................................................................................19
20. Complaint Procedure ....... ............................................................................................20
i 21. Delegalicn of PesponsilAlTy Form ................................................................................. ...........21
22. Legal Rights Compliance.................. ....................................................................................22
23. Non-Discrimination Staternw t ....... ...... 23
24. Personal Cash Accounts / Wou Funds .................................. ..................................... 24-25
i 25. Pe nal Laundry SAf"Ace ......................................................................................................26
26. Pharmacy Services .. .............................,.... 27-34
27. .................
PodiaV;, Services ........................................................................... ........... ..35
28. Privacy Act Statement - Haa,U care Records ................................ .................................. 36-37
29.
....38
Private Room Policy/ Nurdn,.,...................................... ....... ........... ................ ......................
30. Therapy ....................................................................................................................................39
31. Vaccinations ....................................................................................................................... 40-45
( 32. Valuables ................. ..............................................................................................................46
33. Admission and Care Agreement ............... . ................................................ ...... 47-55
a. Security Deposit. .47
5. Late Charge ........................................................................................................... ............48
c. Readmission -- Bed Hold Policy ............................................................................. ............ 49
34. Resident / Family Gulde to Inquiries and Information ................................................... ...... 53-54
I 35. 1-Nelcome" (Telephonara tension) ............................................................................. ............55
35. 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 Retimment Community, is a Christian Nnistr committed to caring for
the body, :Hind and spirit of older persons.
Admissions Policy
It is the policy of the Church of God Horne, a urtit of the Eastern Regional Contrence of The Cl-urdes of God,
to admit and treat A persons without regal to raw, color, national origin, age, ancestry, sex, handicap,
c al ity or re igious cre=id.
Only those applicants whose medical nursing cane, psychological and behavioral needs can be adequately met
by the s afi, vrill be adrnifiad or kept in +,his facility. In &Jd tioa, al residents must meet the i tciat r is of
private pay, Medicaid or SSI paper source.
The Board of Trustees is committed to providing housing, services and needed respwsible care fc r olc r
perms with priority b those who are members of, or aftilia'd with, the Eastern Regional Conference of -i tie
Churches of God.
The same requirement- for admission are applied to all, and residents, are assigned within the facility %rithout
reg" to race, color, national organ, age, ancestry, sex, handicap, i'lmbiiit or religious creed.
There is no distinction ii eligibility for, or in any manner of, Wing any resident service that is pro*cd by or
thgh the facility.
QJI areas of the healthcare center are available to all persons and visitors regarftnas of thieir race, cob-, ,rational
origin:, age, ancestry, sex, hander, disability or religlotis. creed.
All persons applying for admission, ul who are recommending in&iduals to the Church of God biome, are
advised to do so without regard to the perm's race, color, national origin, age, ancestry, sex, handicap,
disability, or religiou3 creed.
Ambular,•e
Ambulance enrollment is .recommended but is not hand!--j ' by the facility. If you desire enrollment, please
c AF,,ct them independently.
4
Chart of Costs Effective January 1, 2011
Nursing Gary Roasts Rates
Faith Wing and Love Wing
Semi-Private $249.00 per day-
R wate $302.00 per day
Personal Care Room Rates
Hope Wing and Peace Who
;Semi-Private $111.00 per day (Rm z01-411)
Private $119.00 per day (Rm30) $130.00 per day (Rm303-313) $139.00 per day (Rm,100)
Credskle Apartments
Studio One Beds One Bedroom, Creek view
One person $153.00 per day $173.00 per day $178.00 per day
Two persons $257.00 per day $284.00 per day $331.00 per day
Mote; There will be a security deposit charged based on a 31-day month at the per diem rate for
roWevel of care. In the event of a Level of Care change to a higher level the residentfresponsible
party will be billed the difference between the security deposits. There are no additional charges while
receiving benefits under the Medicare program white in nursing care (except telophbne, hair care,
personal laundry, transportation, bed hold, bed reserve and name labels).
Independent Living Rates
LeTort Mam Apartanents
lment Monthl y penance F
Person Two Pons
A $.42 $1,264
B M $1,170
0 $868 $1,170
D $853 $1,150
E $853 $1,160
Apart of TyP2
A vartr;,ent 'A"
Apar-ar ent `t3°
Apatumerit *C"
Aoari`t rat `DO
Apartment 'E'
401/ Refund" RMO
MUM
$96.100
$95,100
S81,000
$61,000
Independent Living Rates - Rental Rates
t on-Refu*
$83,000
$73,000
$73,000
$63,ODO
$63,000
LeTort Manor Apert; tents
Apartment Monthly Rental
One Per tin Two PF,,.wns
A $2,000 $2,315
S $1,300 $2,095
C $1,800 $2,095
D $1,600 $1,695
C $1,600 $1,895
Nota: Wort Residents who choose the monthly rental opt on will be charged a security deposit based
on one month rental fea.
5
Chart of Costs (continued)
Independent Living Rates
Creekside Apartments
Apartment Monthly Rental
One person Two Persons
Studio $1,318 $1,803
One Bedroom $1,667 $2,313
Note; There wil be a Securty Deposit charged for Creekside Independent Living Residents based on the monthly rate.
Ancillary Services
Bad Hold (during hospitelizalJon or LOA) Per Diem rate
Cable Television (Nursing and Personal Care)
Cable Television (Independent Living)
Cable Internet
Cable Modem
Clothing Name Labels
Guest Room (maximum star of 5 ialghts)
Incontinence Supplies
Liners
Briefs I Pull-ors
Py+l lar A supplies
Keys
Laundry Service (personal clothing)
Medication Assistance Charge (Independent Living)
Included
$22.00/month
$20.00/ironth
$62.00 one time fee
Cost
1 person - $28.001night
2 persons $33-00/night
25% above cost
25% above cost
25% above cost
$5.00
$33.75/month
$15.00/month
Medications, Medical and adaptive equipment,
Alarm pads, special requests, etc.
Nutritional Supplies
Oxygen Concentrator Usage
Portable Oxygen Usage
CP'AP, and Supplies
Photocopies (copies o; records)
Private Telephone
Purchase Telephone Set
Monthly Lure Pee
Therapy (physical, occupational, sit)
"transportation Services
At oAm expense unless covered by your
insurance or covered by medical assistar
benelb
25% above cast
$3.001day, unless covered under Madicare
$12.00/cylinder,'unless covered under Medicare
Actual cost
$1.28/p9(1-20) $0.85/pg(21-60) $0.32/pg(61+)
At own expense
$30.601month
Actual cost unless covered under 1ltsdicare or
co-payment btl secondary insurance
0-10 Miles (round trip) .......................$22.00
11-50 Miles (round trip). - ... .... ...$44.00
51-76 °iiles (round trip) .................. $75.00
Escorts .................. .................. ...$10.00hour
6
Chart of Casts (continued)
Hair Cary
Wash & Set
Wash, Set, & Color Rinse
Wash & Blow Dry
Wash, Blow Dry, & Color Rinse
Wash & Cut
Cut, Wash, & Set
Cut, Wash, Set, & Rinse
Cut, Wash, & Blow Dry
Cut, Wash, Blow Dry, & Rinse
Wash, no blow dry
Oil Treatment, Shampoo, & Set
Color Rinse
Frost / l1kight
Frest / Hi Ught & Cut
Dietary Services
$13.00 Men's Cut $11.50
$14,20 Men's Cut & Wash $20.00
$14.00 Men's Cut & Mustache Trim $13.00
$15.20 Mustache Trim $1.50
$21.00 women's cut $12.50
$25.50 Tint $30.00
$26.70 Tint & Cut $42.50
$26.50 Permanents $54.05
$27.70 Permanents & Color Rinse $55.25
$8.50 Permanents; in bed $60.00
$24.50 Men / Women Wash.; in iced $16.10
$1.220 Men l Women Cut & Wash; in bed! $28.35
$48.00 Wash, Style, & Blew Dry; in bed $29,10
$60.50 Be-crstr?.b $8.45
Re-wmb & Cu:line Iron $11.75
The Dietary Caoartn nt offers three (3) well-balanced nutffous meals daily as hell as an alternate menu for
personal pre#erence. A PM snack is available upon [west at no extra charge.
The partr nt employs too Certified Dietary tanagers arai a Consultant Registered Dietician 'to provide
special diets and dietary consults Atli rs&dents and families.
Our five-!}+eek menu cycle offam a variety of homemade rents and incorporat , fresh fruits and vegetables
when in season, Menus are posted in several lxations throughout the HornM. Our large meal of the day
servers mid-uol and called Dinner. Our evening nwl is c d Supper,
General !Guest Meal Polley
Limit four (4) guests per resident (as space parmits) for A meals except holidays. Reservations must be made
43 hours in advance for general west meats. if msArv3ti am ,,iot made 48 I?rs in ed-ronce, ai alternate
guest mil may be serled at the discretion of the Dietary Depai eri .
HoUday Guest Mean Policy
On the holidays of Easter, FAothees Day, 7hanksgMng, and Chrisstmas there is a; limit of two (2) guests per
resident.
Due to the volume of guests lhat may wish to dine on these holidays, the Church of God Horne will
accommodate the ffrt twenty--five (25) guess to regizter. Since P is impassible to provide this notice to all family
members, please share this information with your extended family. Thank you ?or your understanding and
cooperation.
I' Families Ere encouraged to participate in special meal event, throughout the year, such as our Parents Day and
f Holiday Buffet.
Extra Ctietey Services
(Arrangements for these provisions should be made through your Social Worker.)
*w'ou will receive a separate bill from our Business Office for these services.
SIZE
.
1
CAKES: stmt i .u.7 f W1 r A
9' Round - 2 layers 16 $22,00
'l. Sheet -10"x14' 16 $15.00
'!z Sheet -12"x17' 30 $20.00
Fd 60 $3000
ICE CREAM:
Hand 6ffed - dishes $1.00
Hand dipped - 3 al. container $17.50
Dixie Cups - (24) doz. containers
Vanilla / Chocolate
GUEST MEALS:
$'i0,4fl
Breakfast $5.00
Dinner $7.65
S r -3
Sunda and Hold $7.65
NIiSCELLANEOUS:
Potatoes Chips - 3 lbs. $9.175
Fret s - 3 lb. $7.55
punch-1 d. $4.00
Lemonade -1 1 $4,00
Iced Tea -1 al. $41:00
C„s - t doz. An lend $3.50
NOTE. AN of the above items include paper-serving products and must be ordered 1 week in advance.
Special Orders will be priced by Dietary D rttnent
,e
:M
I
DVD "A Time of Trensffion"
I acnovAedge that I have vir ;d the DVD entitled "A Time of Transit ' ate' have been provided the
oppodunity to rill gL1SSJcns. I further acknowledge that Guide One Ircurance, the HornWs in-surance company,
recommends a viewing of this DVD.r-
als)
Guest Room
- There is a oust 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 relat'rie will be billed for their stay. Reservation can
e made through the Residential Housing Administrator (717) 249-5322 wdenslon 3085.
8
AMERICA'S BEST MEDICAL
2100 Gettysburg Road - Camp Hill, PA 17011
Phone 1-800-383-5303, Fax 1-800-814-9405
America's Best Medical provides Church of God Home residents with 24-hour Oxygen Service and Respiratory
Supplies. They are accredited by the Community Health Accreditation Program providing weekly service to re-
stock oxygen supplies, change disposable medical respiratory goods, and label and date concentrator supplies
for State compliancy.
Their Mission is dedicated to improving our resident's frictional abilities and overall quality of life awhile providing
high-quality products and services that meet the highest safety standards and levels of clinical proficiency. Their
commitment to service and excellence ensures the premium quality of care expected by our residents and our
Home.
America's Best Medical Equipment Company bills the Church of God Home directly for services and supplies.
Church of God Home then bills the individual resfnts. For residents covemd under
Medicare "Part X or edicakJ, oxygen is inchided in the daily rate. Services to Personal Care Residents will be
billed by America's Best directly to Medicare 'Part B.'
MEDICAID (MEDICAL ASSISTANCE)
Medicaid provides Medical Assistance to limy4 permns aged 65 or over, bind, disabled, or members of
families with depandant chi.Uren. The Federal and Sias Governments join finance this program and it ig
administered b the state. Within bread general Federal Regulations, each state decides 4ligibilliy, types and
range of services, payment level of services, and t trafn and operating P-Owdures.
Medicaid's major distinction from Medicare ' a fo.-m of'rman . Medicam is ? lye of healthcare
pity Business Office should be notified
insurance. V?hen resident resources are cer} to $15,000%, th
immediately. The fo4lo,Ang instructions gill • _ r
1. Res.d nAesponsible party YAI be re:Vor i`-ble~tcr a burial reserve setup a a bank or funeral home with
amount equalizing enough for burial. Tiia wtount set aside should indude amount of iffe insurance plus
additional funds. A copy of that reernant should be cubrm ted to the Businass Oifice.
2. When all assets are reduced to $2,COO.00, call the Bus*,ow Office for appointment for guidance in the
enrollment process.
It is the legal responsibility of the POA/Representa€ve False to complete the application and enrollment
process for Medical Assistance baneft. Every effort will be made by our Business Office staff to assist
you. A checklist (pg12-13) is being provided' to you with guldefines that will help you get started. Please
be aware however, that it the POA/Representatilve Payee dces not follow through in a timely manner,
that the Church of God Home, Inc. reserves the right to file the application on the resident's behalf.
3. The Centre County Office of Aging will do a level of care assessment of the resident, known as an
"Options Assessment' and forward the results to the Pennsylvania Department of Public Welfare (DPW)
for further follow-up by the Centre County Assistance Office. Should they assess for a different level of
care other than nursing, andlor the resilient does not qualih fnr Medicaid, the facility reserves the ilght
to terminate the admission agreement and will work Vith_ residentlresponsible party regarding available
options.
9
4. To appeal a decision regarding a Nedicaid Assessment, contact:
The Pennsylvania Department of Public Welfare
Huntingdon County Assistance Office
(Cumberland County Long Term Care Unit)
7591 Lake Raystown Shopping Center
Huntingdon, Pennsylvania 16652-0398
P: (614) 641-6447, M237-7674
Fax: (814) 64&41
To appeal a decision regarding a level of cares assessment, contact:
The Cumbedand County Office of Aging
Long Term Care Program
Human SerAcn Budding
1100 Clamant Road'
Carilse, Pennsylvania 170`13
(717) ;M-HI 10
5. After preliminary papers are sent to the assistance ofd, the residanfs security deposit %AH be applied
to mom and turd and any balance due billed ft responsible pare.
6. After being approved, Medicaid mqukes',? at the reslfries morithiy ii= me be su'omiited to the facility
each month. Of that aiwunt, the resident will receive the approves 5.00 morifty allowance for
histher persona rte, he resident, responsible party or Lhe fa6iity may. handle this persoc+ money.
7. Altowa& expense from resident mc;nt'niy income is health insurance. Afar accept-once into the
Medicaid program, biliipg for health insurance should be forwarded to the st in our business ofd.
The monthly e pence for INs insurance is deducied from she resident's monthly income and the balance
;s applied to he room and board. The state pays be facility a per diem (daily) rate times the number of
da)i in the month that a fes dent, approved for Medicaid, occupies an accomnrodaton. After resident's
res?crisibility is appliad io this amount, the balance is billed to the Pennsylvania Dep:?.?entof Riblic
Welfare (DPW) cn a mortthfy basis.
aft for personal needs may be presented in the rasidents name to he facility har0ling funds for
rcirnbursement. Upon enrollment into the k-Wicald progmn, the recitlent will no losngar pay for routine
hair core, incontinence supplies, non-emergent medicaf apontment tru-rispc; tajNi or personal laundry
service. Medicaid wiN, h yer, poy for prescription dn.gs, doctor visits, dental services and eye
enarninations.
8. Upon transfer or discharge for hospitalization of a resident receiving medical assistance benefis, the
facility will hokt a bad.
10
CHURCH
OF GOD
HOME
"Committed to Caring"
Medicaid (Medical Assistance) Residents
1. The Church of God Home, Inc. requires a copy of monthly t quarterly Medical Insurance premiums. As
REQUIRE; Y . Ivarda Stale Regulations.
r
2. ?+edic°a! Insurance sns will be deuctet! from the R3sident`s monthly Income and the balance of the
ir,oome less a 45.00 alts ance will be applied to room and hoard.
3. Prescription drugs, h?yslclin vas ts, dental seria.eces, arvi ya exawaficns Are covered by Medicaid, but
only with part pafinp lis s and oplithalrao4 sts. Potential charges Viii be discussed with responsible
party on an ir&vidual basis, when reruesting non-l elcipating provklers.
4. Services furnished at no chafes to 11-4 Resident areas flows:
• Norri,al Shampoo every twc, weeks
• One pen, ekM three months
• Transportation to and from medical appointments is paMded (Distance to
appairitments 411 be discussed on an individual basis)
• Non-jinergent ambulance Imnsportatian
• Personal Laundry
• Insontineni Suppfes
• Fed iiold in the eve .,it of ht iita dm
'The t'allorA services wilt be char:
• Any hair care request beyond the above list of provided services
I ransportation for a personal use
• Telephone basic charcfes, and long distance charges
5. Bed hold days due to hospitalization will be fifteen (15) clays per hospital stay. Bed hold days due to
therapeutic leave YAII be thirty (30) days per caler r year.
3- - r tl
(Dat&)
1
(l?esidcxrthie'spons?ie Petty)
(Resident Name
(Faa`rFty Represen '
ti
Medicaid (Medical Assistance) Resident's Checklist
HUNIINGUCN COUNTY ASSISTANCE OFFICE
(Cumberland County Long Term Care Unit)
7591 Lake Raystown Shopping Center
Huntingdon, Pennsylvania ISM-0398
Telephone: 1.0-237.7674 or(814) 641-017
in order to dete<'rnine eligibility for nursing home Medicaid enrollment, the Centre County Assistance Ofte 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 Cprd(s)
2. Prirrof of Uala of Birth
- 3.Health Insurance Cards
A. Medicare (R.dtNV-'1 te'Blve C d(s))
S. Capital Side uress / Highmark Blue Shield Care(s)
C. Any other health i,1sumope plan(s)
- 4. Heaith Insurun Premiums, provde frequency and amount
- 5. Long Tenn Care Policies, provide monies received and terms
6. Power of A=grey or Guardianship papers
7. Read HIPPA disclosure and complete the HIPAA disclosure requestPW1815
8.Verifrcaton of ALL GROSS VA in na needed. (if you are not receiving benefits, you will need to
apply for potential benefits in order to be eligible for Medicaid.)
9. Vefflcarfoa of ALL G OS income - pro vide current award letters, pensions, annuity income, and
interest income
j
10. PrvAde current statements for ALL hank accounts, &=ks bonds, tsuqs, IRAs, K hts, and
Annuities -- mast provide values of i
11. Personal Cam Aunt (PCA) Balance
i
12. Verification of all resources sold, transferred, or given away during the past 5years (5 years for a
Trust r=und -- provide disposition, amounts, and dates
13. Titles, vehicle registration, and insurance for aft v+ehiclas owned, including boats, motorcycles, and
trailers
12
- 14. Current cash value of all life insurance policies. Verification should include company's name, policy
number, type of policy, face amount of policy when purchased, ownership of policy, and statement on
the current cash value from the insurance company.
- 15. Deed to burial plot(s) or statement from cemetery
16. Copy of Burial Trust 1 Reserve (including Statement of Irrevocability)
- 17. Dead to all property and it's current market value - if transferred or sold within the last
5 years, provide a copy of the new deed and the settlement sheet for all sold property
_ 18. Title to mobile home and it's current market value - if transferred or sold min the last
5 years, prov& a copy of the new cued and Ov settlement stmt for all sold property,
19. Any unpaki medical bills you wish to see Medical Assistance would cover
20. Rent / age payment proof
21. Utility Bills
A. Electric
B. Gar
C. Gil
D. Heat
E. T.-lept e
F. Water
G. Sewer
H. Trash
22. Dome Tax Returns - for the past 5 mss, pmvk a all sa es and 1099 Forms
3
fy
I 3
4
t d
l3
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 cae in a hlle e-?ipat ng skilled nursing facility
following a three (3) night hospital stay and your coridition mires dally &killed nursing or rehabilitation services
which, as a practical matter, can only be provided in a skilled nursing facility.
F
A skilled nursing facilily is a specially qualified facility, which has the staff aryl equip nenI to pmv& skilled
nursing care or rehabilitation servims and other related health servi as.
Hospita! insurance helps pay for care in a skilled nursing facility if all of the followir;g five concerns are met:
1. You have "a in a hospital at least three rights in a row, before your transfer to a participating skilled
nul F'rg facility.
2. You are iransfer: ed to the skilled nursing fwity f use you reqA9 carne for a cDndition, vNich was
ire ed in tite hospital.
3. You a admitted to the facility within a short time, generally wAin 30 days after you leave the hospital.
4. A doctor certifies that you rid, and you receive, skilled reha itetlon services on a daily his, and
5. The Medicare intermediary or the facility's Utilization "Review "omr tee does not disappran; your stay.
All condifions must Le riet. it is espeaaliy, itraporiant to re.,m the reguimment that you must heed sl<alled
nursing care or skilled rehabilitation services on a daily, Wis.
i Skillsd nursing care means cara tat can only be Perfornisd by, or under the -supervision of, rcensed nursing
1 rsori e€. Sl filled rehabilftation service; may include such sankes as phy* 1, occupatio.rd, and speech
tlzaraples per bared by, or under the supervision of, a ?f?lonal lhamplst. Tl e skilled nursing care and
skied rehabilitation serices you receive r Must be based on a doctor's orders.
Po*, wl insurance will not pay ,or yc<ur stay if you rmd skilled nursing or rehabilitalicn services only
l occasionally, such as once or hAca a week, or if you do not need to be in a skilled inursing facility to get skit
services.
When your stay In a skilled nursing facility is covered by Medicare, hospital insurance helps pay for up
to 100 days each benefit period, but only if you need daily skilled nursing care or rehabitltation services
E for that lung.
14
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 benefit period, hospital insurance (Medicare Part A) pays for all covered services for the first 20
days you are in a skiff nursing facility. For the 21 A through the 1001h day, as long as you continue to meet
the criteria flor daily Skilled Nursing Care or Rehabilitation Services, hospital insurance pays for all covered
services except for $141.50 a day. You may be charged up to this amount by the skilled nursir. facility or
it may be picked up by your secondary co-insurance.
Effective Mtay 30, 2008: Medicare requires that each resident ! responsible party indiczte their choice w th
regard to a bed hold if any nursing resident is hospitalized.
Major services Or d when you are In a akltlecl nursing facility
Medicare hospital insurance (ledge Part A) pays for these services:
A semi-private room, 2 beds in a room
¦ All your maxis, including special diet's
Regular nursing services
Rehabilitation services, such as physical, cccupationai, and speech therapy
Drugs furnished bu t'he facilit during yvar stay
• Blood transfusions furnished to you during vcur stay
Meedical 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 faclflty
Meft-an hospital insurance (Medicare Part A) c ces not pay ibr thess M'icee:
Personal convenience items sucij as a leieowr`.e in your room
Pilvate duty nurses
Any extra charges for a private room unless it is de±ermined to be medically n sswy
• Tr??spcrtatien
Acme Lab.
• 1lair Care
?erso al laundry sv price
NOTE: if you disagree with a decision on the amount' Medicare will pay on a claim or whether Medcare
covets Services you rive, you gays have the right to appeA the decision. Feel free 10 contact
Medicare at 1-800-633-4227.
The Church of God Flame reserves the right to withdraw from the Medicare prog€ m.
15
I!""OBILE X-RAY IMAGING, INC.
Mobile X-Ray Imaging, Inc. ("MAJ is the most advanced, most efficient, most complete and the only local
mobile diagnostic X-Ray1t11trasound/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 facift 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:
Dit>cetic :-Foy Stcrdies Electrocardiogram Services
Holler Monitor EKG Diagnostic Ultrasound rExaminations
Our X-lay and Ultrasound exams are interpreted by Ouantum Imaging and Therapeutic Associates
(fon,T*dy known as A.Z. Rittman Associates), one of the foremost radio!ogy physician practices in Central
Pennsylvania. All EKG and cardiology related exams are nerpr$ted locally by Associated Cs?rdblogiata,
P.C.
MXI has introduced Me following significant improvements to the rnoNe diagnostic tQsrjng industry in
Central Pennsylvania:
MXI was the first provider to An wphisbcated No f e(pna, porta a X-Ray units, whr.h
pr duce superior kwges with less ratration exposure.
• We were the first mobile service it Central Psrnnsylvenia to prove 24 hours a day, 7 days a
week X-Ray wAce with round the clocks interprelations.
We are ire only, mbile service in Central Pennsylvania, w*h cis our own ultrassound
examinations, -Nhich gives us c ornplete control over gcuality and sere ce efficiericy.
w Via arro the only mobile service in Cantat Pennsylvania to provide ultrasound service on 24
hours par day, 7 days a wok basis, inchAing inLarprekations.
Our services are covered by medicare, Medicaid and most major insurances.
Mobile X:Ray :malting, Inc. 5120 Lancaster Street - Harrisburg, PA 17111(717) 5614940
psychiatrist
The Church of God Horne, Inc. offers psychialufc services specking I:n geriatric 3errvi.es. Philhaven
Hospital has contracted with the Church of God Home to provide on-site services for our senior adults.
Billing for this psychiatric sere All be as fobs:
" If the resident is private pray, Philhaven lcspital will bill Medicate first, than yow supplemental
insurar:ce. If ftre is sVII a balance, then be responsible par ti ,41 be bird.
• If the resident is on A im Assistance, Phillaven 'Hospital will bill Nedicar first, then your
supplemental insurance, and Medical Assists third. There vAll be no bill to responsible perties.
Feel free to contact Philhaven Hospital at (717) 270-2413 or 1-868-740-8211 if you need further
clarifiastion. 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 vAli be necessary for residents to get assistance from their family member and friends.
Ail prospective residents will be informed of our Facility's smoking policy.
Serialized Services
If your have mantal retardation, a physical cliff, or other d saWy which occurred before the age of
twenty-tom (22), you may be eligible to r,;?celve suWd ssrvlces that would help you to li?ie with your family,
in your own went, or in meter community sed ng. You may also be eligible for specialized services.
For more in1brmation, if you have mental retardation Centre Regional Office of Developmental
Prcgirarns at (717) 772-6507. If you have anctner disability (otter an mental ratan n or mental illrrsss)
call United Disabilities Svmca at (717) 3911-1341.
If you have rental illness (other ihan damentia) anti you do NOT need nursing r sWicea, you may be
el' to receive support servers that v tr'cl help you live in your own apart,nent, in a group home, or
another community setting. For morn informaLcn, call (717) 772-7490.
if you are not sa f'ied With the Ps se you receive, call the Disabilities Pights Network of PA at
(214 Z 23tt170.
Transportation
Enrollment Mh the local ambulance service is not raquiret4, but is recommended. Not all medical
appointments require a€rWance stretcher tray rt and me often handled by our whee eir lift van.
Physician ordered medical appointments ere to be scheduled thresh our nursing &-partment ?A local
physicians, as the Churcri of God Rome does not normally transport to o1jt-of tcrwn medical appointments.
Fa ii y rnambem A be rant to determine their ava Wity to provide trar}wrW ior), or to serve as a
companion to accompany residents during hnsp4 throulghout the appointment, and on the return trip.
fvled4al eonsvlt eta accompany residents to their app tn:artb often tries is a need to adjust for a
meal or medication routme.
Families providing transport are requestd to follow the sign out pr=edures and are asked not to schedule
I'ollowr-up appointments unless they are intending W wide the trarsportflon. In either event, pease be
sure to inforn the nursing depa trnentof the scheduled foi!ow-up appointment.
CITE: Transportation provided by the facility will be at an extra charge. Please see "Chart of Cost"
for fee schedule.
17
UNDERSTANDING RESTRAINT USE
In order to protect our residents from harm or to promote them to a higher level of independence, it is
sometimes necessary for us to use a physical restraint.
Physi restraints are any manual method, material or equipment attached or adjacent io the resident's
body that inc ,duaf cannot remove easily and that restricts freedom of movement or norma access to
the resident's body. Examples include; bedside raHs, leg restraints, arm resU*nts, had mitts, soft ties,
wh hair safety, bars and ged ckzirs. These devices are NEVER used as a disciplinary actlon or for the
onveeiance of the facility to control behavior.
Restraints are initiated only after less restriclNe measures, such as positioning piilow, pads, wedges,
r4E,Tcvable lap treys couples with arpropriate exercises, or other 'enablirT, ' equipment, have been
derimistrated to be insufficient. The least restrictive dew would be then implemented followhg a specific
doctor's order and/or a prone call to P.O.A. I next of kin. The resident will ;hen be reviewed in the next
Restraint Redliction merUng.
The following Is a comparison of potential BENEFITS and RISKS of restraint use:
Potentlaf Bewfb
• Prevention of falls which might result in injury
• Protects from other accidents or injudes
• kcal treatment albwed to proceed without resident interference
• Protection of o}her residents/staff from physical harm
• Increased fling of safety and security
Potential Risks
• Accidental injurl Fom the restraint
¦ Chronic constipation
Ir conJnence
¦ Pressure sores
• Loss of muscle toile
• Loss of ba'ance
Reduces appetite, dehydration
• Loss of indepandent motility
• Increased agitaicNi
• Symptoms of depression, vOthdrawal
Contractures
• Reduced social contact
18
44M
CMRCH
OF GOD
HOME
Tommi/uu 10 Caring"
Advance Directive Policy
It is God aline who opens the door to earthly life. It God alone who has the right to dose it. All
experiences of life provide opportunities for evangelism, ministry, reconciliation and re-assessment of
j,rissrif.
The Church of God Home reougni?es the right of an individuai bo make and change ded-sions xncertling
their rne&A care in consultation with their physiclian. Thk; indjies the dot to aocept or rafusa artificial
te-ans of susUnhig life when These decisions are se forth in properly executed Advance
Cirectives/Healftere GuideHnes. In no it;stance vAll the Church of God Home comae homicide,
ecqhanasia, suicide or aided suicide. In the absence of advance directive, tore of the r-askient mil be in
a;coft,are pitta aprreirtty acceplad medical standards.
Rega-diem of the residmCs decision about Iife sustaining 1reaf nt, supportive and compassionate carp
for maximum comieft will be provided: Thm measures include, but em not limited to, oxygen, medication
io mf.eve pein, food and hills as tolerated, alorag withh enr lional and spiritual suppcrt.
Should the o=sion arise whey, a resident usould mius+e nutrition or medical wWortive mvioes with t e
interatlon of prematurely bring their We to an end, the dome would encourage and recommend ownselir
and evalua 3n. I he f3rnfly 51 ouk! T-v inforn, ad and, if a satisfacloiy resolutictl cannot te achLeved as to ft
care ci the resident, the FIorrta warm assist the family in the attempt to rstocate the resident to another
facity as scan as possible.
aclcnow that t ha r ivad a dupiicete copy of the abme Advance Directive Policy and have had
pro-Mad the ^pportunity to ask questions relating to t p-, sarne. I have also been offered the oppoftiity to
complete an Adv Nective.
(Date)
19
1/1
(Facility Repmwtati
42
CHURCH
OF GOD
HOME
,,Committer) to Caring"
Complaint Procedure
Policy: It is the policy U tie Church of God Home to have a complaint procedure in place to
enjfy and address concerns.
.
Purpo : To assure the Home's Ili Statement is being upheld to its highest inWgdty.
Procedure:
1. Any written or oral complaints presented by or on behalf of a Resident to the Church of
God Horne r: gWing cm, operations, or management of the Nome shall be directed
to tt?e Administrator of the facility.
2. If a resident wishes to tae a wrftn complaint but needs assistance, ft Social
Worker shall assist the resident in wrifing the complaint.
3. Within two (79) business days after r*tifrcation of a written complaint, a status report will
be provided to the complainant andkr designated person, explaining the steps t the
Home is taking to investjata arid address the compUnt.
4. The Church of Goy! Horne shA,, ensure thA Resident's safety if complaint identifies
harm or potential him.
5. Within seren (i) days after the not icarion of a *Y%n complaint, a copy of the w4tten
decision explaining the investigalkn findings and plans of action will be given to the
complainant and/or designated person.
5. All complaints vAN be placed in a binder Yvitn the findings and plan of oomction. The
PCU Ada inistr&r will maintain the binder.
(Fas t Na me)
?r
(Favlfty Representative)
20
y
y
CHUM
OF GOD
HOME
"Committed to Caring"
DELEGATION OF RESPONSIBILITY FORM
As a result of rrkdicai md/or physic condition or personal choice, residents find it difficult to understand
andkx sign for their Pas dents Rights and/or their Admission. contract. Some residents, aftugh not
Ieg y judged incompetent, may be found by a physician to be irapab!e of un derstzndIng these fights and
contract information. Therefore, a resident may choose to designate an irufivi64 to at of their behaff by
permik,g them to sign the necessary €orrm indicetir g receipt of this information.
tN is med;caflylph capaNe of
(Name of residarto
understandling Residents r hs but designates this to:
3
(D)
Na?
(Re n spors-f1b;e Fed)
I
(ReAert Name)
vv
(Feebly Representa&P
21
%10
d a idb aminhk
CHURCH
OF GOD
HOME
"Committed to Caring"
LEGAL RIGHTS' COMPLIANCE
RESIDENTS AWARENESS
COMMONWEALTH INFORMATION CENTER
402A Finance Buddin
Hanisburg, PA 17120
Telephom: I -000-932-0784
PENNSYLVANIA DEPARTMENT OF AGING
555 Walnut. Street
Harrisburg, PA 17101
Telephone: 717-703-7247
PENNSYLVANIA DEPARTMENT OF HEALTH
DIVISION OF NURSING CARE FACILITIES
HARRISBURG FIELD OFFICE
132 KJine Plea., Suite 8
Harrsburg, PA 17104
Telephone: 717-753.3790
CUMBERLAND COUNTY AGING &
COMMUNITY SERVICES
OMBUDSMAN PROGRAM
HUMAN SERVICES BUILDING
1100 Claremont Road
CarLnle, PA 17013
Telephone: 717-240-6110
/ r
(Date)
PENNSYLVANIA DEPARTMENT OF PUIBLIC WELFARE
HUNTINGDON COUNTY ASSISTANCE OFFICE
(Cumbedard County Long Term Cars Unit)
7591 Lake Raystcwn Shopping Cent r
Hwitingdcn, PA 16£524353
Telephone: 514-641-6447
1-800-237-7674
MID PENN LEGAL SERVICES
401 East Louther Street
Gaeisle, PA 17013.
Telephone: 717.243-19400
ARt
(ResidentlResponsbie Party)
(Resid???t?t mw)
(FaciltiY Rresenta
22
C OF GOD
HOME
"Commined ro Caring"
NON-DISCRIMINATION STATEMENT
in accordance Frith aapl. Federal and State cMI light laws wnd rt latory requirements, you, as a
resident of ti facility, have the right upon admission:
• To be ptOvidC3G services at this facility and to be refertred tr services at ocher 'es without
regard W your race, wlo , ml?+.on creed, han icap, ancestry, national oft_ n, age or sex.
To file a complaint of discrimination if you feel you have been d scriatinated against on the basis of
your rare, color, religious creel), hWicap, ancestry, national origin, age, or sex. Cornpieints of
dls,cAminakri may tiled with any of LJ e tolvwing:
President/CEO
Church of &d Horne, Inc.
801 .14 ,Hanover Street
C sle, PA 17013
Phone: (717)' 249-5322
Department of Health and Human Sr rites
Office for Civil Bights
154 S. Independs. ve all West
Suite 372
P Welphia, PFD 19106-3499
Phone: (215) 861-4441
Pennsylvania Humn Relations Corn)vrt
Harrisburg Region Offer
Ri rfron! Office C2rttr,
1101-1125 Smith Front Suet, P FIM
l anisburg, PA 17144-2515
P'hom: (717) 787-9794
1
(male)
Department of Public Welfare
Bureau of Equal Oppof,=4,
Central Regimal Office
Rm # 223, Ho3llh & `Alelfare Bldg.
P.O. Box 2675
Harrisburg, PA 17120-2675
Phone: (71711783-3063
VRO
(Reslden'JResponsible Pally)
• L-dj-14-w (Resident Name)
V. Wlil d _11
(FadEy Repres,°nta6ve)
23
Personal Cash Accounts (PCA)
To establish personal cash account (PGA) at the Church of Gal 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.
ith maximum of $30.00
3. Daily w dr
Note: Regular business hours are 9:00 a.m. to 3:45 p.m., Monday L rough Friday, except holidays.
Deposits
The resident or family member/ raspor:s hle party may despos cash or chi elttfr at cur Business Office
(Henderson House) or in our Lobby Front Office during regWer Miress hours and of course, by mail.
Personal casab accounts are only meant to provide casual speruiing money fbr residents,
fisburrrrents
The resident may come bD our Lobby Front Office during business hours to request money. A resident
charge slip is complete and the resident or family member / responsible peffy sign the dasbuizemant slip.
Purchases for a resident imay be made by family or desigr?aled person and a receipt should be su6rnittec to
our Business Offica for each reimbursement from the rasident's accent, i.e. `firs, shoes, clo%N, etrr.
PDA's are rec or ailed monthly to the beak statement. interest paid by the bank is pro-rated to each axount
and deposited into each wcount accordingly. Quarterfy statements zire issued, ebng with a cover letter to
be signal key the residant and retumed to our Business Off%a.
Each resident a; the facility has the right to open a pefsonal cwt acoour`rt (PCA). All a=unts, regardless
of the resident's status, are handled in the same manner.
Upon the death/dischar of a resident, the account b race shd be returned to the executor of their VA
or a tho ized repnesentaM of their Estate with iii thirty (30) elves.
24
Pomona[ Cash Accounts (cont )
CHL
OF GOD
HOME
"Comrnirned ro Caring'
Authortration to Handle Personal Funds
(Dab)
Dooeted Funds
Q
(ResideOReq=mWe Party)
M
C
f
(Pasident Ni")
k/ Aratta
(F
When reside ifs amts reach $15,000.00, fan tylresponsible party should oonW our Business, office
Family mamber ! res iL.zt-,' y wiH have to apply for Meftai AssWan m. 2es<dpnts with no wily
member! respond rty, o sin4ss i fi, tce r t apply for Medical ?tsta?e.
Residents wRI raoeivo' 5.0nthly from #teir inoome for pemonal needs. Qit)er mmies may
depD fted into each PeA, as the resident or fanny membert respcnside per desires.
-)) -t` J-1-
(Dote) ( es n3vee Parv
(Resident Nam)
a
V fflt
(Fediity Re nt
25
s
r
CHURCH
OF GOD
HE
"Committed io Caring"
Pet` na{ Lrundit Service
This to advise that the personal laundry v411 be laund8ked withtni outSide (circle one) the facility.
NOTE:
• These arrangements can be changed with roti#' iaa to Smial. Services or Charge Nurse.
• Residents I Responsible Parties pro?Adina laundry services need to provide a container v a ild and
box of plastic bag liners for #ie purpose of stcdng laundry.
• Volumes z am avatiable to assist tWith labeling clothing I personal items. Plem contact Social Services
or Charm Nurse.
Dry cleaning and Ateration SerAcpas are not prod.
No vml items are accepted.
(Date)
{ReanU-P- Pity)
V. A
(FaciWRepre is
26
PhairnnacY Services
GEL A?Iffi
Specialist in 28 South 2"' Street
Newport, PA 17074
Continuing Care RY 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 -e icient manner possible.
' Phannacy services for Long-Term Care or Personal Coe Residences are mandated by government agencies to
offer additional services, which you may not have been accustorned to in a normal retail pharmacy. These
adultional services are designed to aid in your progrm (or that of your lop ed one).
We would like to highlight some of the services we {row to give you a better understanding of the many
unique benefits we have to offer the residents we server
• Controlled Packaging System - Routine tobletlcapsule medications are p aged in a 30-day seed
i;lis!e; card enabling nursing slag to acimigister raedicatfons in a controllad envirmment with extreme
accuracf and safety.
Medical Records - A media records staff rrem ar maintains and p?tints mo nthiy char`s that are uteri
by the caregivers, nursing staff and physicians.
? 24-flour 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 ti, 7 days a week to
reset t1 iese erns. envy nos.
Gonsuitant Pharmacist - A Consuitant Pharmacist ,s assigned to our fac ities to review residents'
charts on a monthly basis and to interact with the nurses and physicians to awitor the resid?>ts'
condition. In addid?n, they wili make recommendatirts to the physi cans when a better and more cost'
effective therapy for the existing w,idi ion becornees avallable.
s Delivery Service - Dedications vQ be delivered to the fiadctiiiy at predate mined Urnes on a daffy basis,
ensuring tier delivery of all medications ordered.
Billing - The staff at Continuing Care Rx will handle a billing process for sil types of reimbumement.
Continuing Care Rx is a merrbeer of most insurance groups and we bill directly to these insurance
groups. Should you belong to an insurance group with %1kh we are not currently affiliated, we zv+if
immediately pursue enrollment in that program in an effort to meet your nos and ease your financial
respo rsibillty.
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 high quality of pharmacy services to all of the
residents we serve, We look forward to wvorking dosefy with you (or your loved one) by providing the best
service available in the long-term care industry.
Dote: Please contact Continuing Care RXvhlh any questions or billing concerns at 1-84,10-675-Z?79.
127
PrPrary Notice
CO€#TINWNG CARE, Rai
FOOT OF PRIVACY PRACTICES
T141S NOTICE DESCRIBES HOYi MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED ANC! HOW YOU CAN GET ACCESS T>:O THIS INFORKA.TIOK
PLEASE REVIEW rT GARF-FULLY.
1. our Duty too Ssfeguard Your prot l Inform on
We are committed to preserving the privacy and confidentiality of your heoldi information. We are required by certain state
a d federal regulations to implement policies and procedures to safeguard yum heul'.b informattion. Copies o °out privacy
policies stand procedures are maintained in our business offtce_ tYe arc required by state and f1sitrai re rations to abide by the
privacy practices described in this notice, including any future revision thAt the tray mab to the notice as zany become
ne€;essaty or as aau%orkW by k v.
to dividually identifiable information about your pest, present, or uture heallb or cmdidm the provis"i of health cam to
you, or payment br the h?th care tresatr erA or sonricss you receive is considerer3 protected heu'7dr i4brr.vaon (PHI).
Accordingly`. we am required to prcmide you with this Frivscy Notice that contains in€arrnatirnt regarding Our Uivacy
practices to explain how, when and why we may to or diselos. your PHI and ymr rights and our obl:gzdm s ; egat?g mty,
such uses or di,closurnm Except in spccified circumstancts, ae must use or disclose only the minimmm antomt of Pill
necessary to accomplish the intended purprse of the use or disclosure of ruch ir+?rnaation.
We reserve the right to change this notice apt array time and to maize the revised or charge d notice effort for pfit that we
already have about you as well as any information we r=ive ira the tnttae about yon. Stweeld to revisdcharage this Privacy
N , we will promptly past the revisions [insert location, such as co a wcbsitel. -101, ASS mayirequeK $ad obtain a coley of
shay newirevised Privacy No?ice from t ie contact paws i6ontified on the test page of tlti.- notice.
Should you Itsve questions axone.-ruin j oar Privacy Notice, our contact inkmoatice is listed an the {est page of this document.
H. How W>et dodgy U" and Disclose Your Protected Heraltft IttbDt"tl'sletlt o
Wa use and disclose l roteat 4 bealth information for a variety of restsarts. We have a limitad right to use and/or disckw your
ptoteacd heralth inform.?sion for purposes of treztrncnt, payment, or for health care gmUtions. For other ems Ind
disc:o=rc3, you t ust give: us your written authori2o ion to release your protected hemp hf"ation usla? the law ptn nits
or requires us to Fnsxe the arse or disclosure without yourauthorizt?oo.
Should it be eme necessary to release or giNT access to your protected bealth information to an owside party patio ring
services oat our behalf (e.$., mairtaaining oar computers), w: will require the parrty to have a signed agreeutent with tan that the
p? win extend the saame,deg ofprivacy proteako to ,roar infomation ads w do..
The privacy law permits tts to snake some uses or disclosures of your protected hLmlth ±mformatlon without your consent or
authorization. T'he following describes each of the different ways that we may use or dieclos: your proWed hcslth
i?nformaation. Where appropriate, we :nave included examples of ttte different types of uses or disdowa, rpesa include:
i. Use and Dl cures Rusted to Treatm€ct
W may disclose your protsctu! healib information to thetse who aare involved is pros+iding medical and nursing csare
services and treatments to you.1'or exam; a we may release protected heralds iaformeetio3 i about you to nurses, n iag
assistants, m dication sidesltechnici s, medical affid nurso-, students, theraspists. other ph_ medicW records
personnel, other caonsultants, physicians, etc. Lyle may' also disclose your protected healdt information m outside eta
erforming other services relating to your treatments such as long term care facilities, hospsitals, diagnostic labora€ories,
home health/uospice agencies, family mernbcrs. eat.
2. Use prod 'Uild res Related to Payment
I We ma use or disclose our rotected health ink oration to bill And collect payment for items or services Rte provided
) Y Y p
to you. For exsmple, we may contactyotu insurance company, health plan, or another third parry to oltain payment for
I services we provided o you.
?eyz.y? Notice
G8
prlvacs Vofke
3. Use and Disclosures Rrlstcd to Health Care OP41"Itifts
We may use or disclose your protected health information for the performance of certain fimctionss in monitoring and
improving the quality of care and services that you and others receive. For example, we may use your prouctedl health
information to evariuate the effectiveness of the care and services you are receiving. We may also disclose your proic cd
health information for auditing, care planning, quality improvement, and learning purposes.
4. Use sud disclosures Refaced to Treatmentt,?ltertnath?ea, Ilesitln-bated Benefits snarl Services
We may use or disclose your protected health information for purposes of contacting you to inform you of treatment
alternatives or hearth-reisted 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.
HL U:105 earl Disciosur" Requh%q Your Wrlttrarn Aut ritaftn
For uses and disclosures of y(w p:?xcctcd health information beyond the abew excepted pun ores, we are required to have
your written utt$w zation, except as otherwise required or permitted by law. You have the right to revoke an awborizodoo 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 umm your iut)Kvizt;tion. Your revocation request must be provided to us in writing. {Jar, contact information for
l urpwcs of rtvokin3 your outhodmion is listed an the last page of this documcm. You may use our dt4horiscaion for Use or
Visclur r of rroitc+vd Hice.rh lrafa-nwdon form and/or our RevecxIon of anAuthcritavo F*rm to submit your request to
us. Copies of taut- forms are available upon request.
Examries of uses or discknures that -au!J require your written authorintion include, but are not lirmitw to, the following:
1. A ^qu^s to provide your protected neallb itthrmition io' to attorney for tyre in a ei-cfi litiEstioa driers.
2. A request to provide certain information to an insurAnce or phannaemnical company for the purposes of providing
you with inforrnation relative to insurance teneGm or new medic atious that may be of'inrWtst so yen,
3. A request to provide ?A to another individual or facility. where no exception fvw the written authorization
require mcat applies-
IV. Umm or Disciosuros of trtformatfott Basest LIPon Your VW t4# AgMernent
in the follovring Situations, we rray+ disclose a HID ited Smexnat of your protected health informatics i Bare provirlo you with an
ad-mric orn.l or written notice and yon do not object to wash re)mR or such rclea}ss is not otherwise prohibited trj law.
However, ifthom is all ctnerl'Im ~; sitwwoa and you are nnabie to object (e.g., because you moon aot pres?nt or you vtm
i incapwitsicA disclosure may be mado if it is consistont thiih any prior expressed wishes and aiscloswe is dafertrrined io be
in your best int:.r Wit= x disclosure is r-gate based on these or en-W.cy situations, we will only disclose protected
he¢Itlt in."aarmation rclevunt to the pem" a involvement in your care. For =ample, if you are bavurg an adverse rmcdou to a
medication, and arc not able to communicate with us effectivel)" we may inform a family member invoh-r-d in ym case of
your drugregitnen.-d Possibte side effcds. You will be informed xxl given zn opportunity to object to further disrkutres of
such in(mmat m as soon as you are obit to loser
We may disclose your protected tnealth infomatiom to your fsatily members and frimils who Pre invc-b-od in your ektu ea
who help -,my for your care. We may also disclose your protectod health information to a disa,-ter aelief organiraficA ,nor the
purposes of actir*g yoxrr fmnily and/or friends about your gene4 +l condition, location, and/cat stamps (i.e., whither you are
alive or dead). You may object to the release of this information. You MAY ttse our Request to Rritricl the Use or Disclarure
of Pro:eras/ Hrcld h#bnttuteon former to notify us of your objectian or your vbjectim may be made ornlly. Our contact
information is listed on the last pone of this document. (See also Section VI, paregmph 1,)
V €lsrtaate wO Vkxk*ums of lnf6rMation That Do t R*gWre Your Consent or AuUmulzallott
I State and fZderai Was and ragdlations in some instmM either require or permit us to use or disclose your protected bealib
iniorinatioa vridtout your consent or authorization. The uses or disclosures that we may totals whitout your cogstnst or
autho6matiolt inakule the following:
1. W lwo Rerlatlred by Lair:
We may disclose your Protected health information when rewired by federal, state or locatl law.
' I F?rivaW Notim
29
Prhucy NOrtce
2. Abase, Megkct, or Domeatie Ydol wm:
As required or permitted by law, we may disclose protected health information about you to a state or feleras 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
trade such a disclMTC.
3. CommDnicabte
-o the extent authorized by law, we may disclose information to a person who may have been exposed to a
communicable disease or who is otherwise at risk of spreading a disease or condition.
4. Disaster ROW
We may disclose protracd healtb information you to gotresmnetat entities or ptivattogmizations (shell as the
;led Cross) to assist in disaster relief efforts.
& Feted vad Drug AdministrAtton (FDA):
lvre moy disclose protected bm&h infasaandon elbow you to the FDA, or to an entity replakd by the FDA, in order,
for vmrriple, to report 2m adverse -nnt or a defeat rekttd to a'drug of medieal drvM
6. ForPuWIc Health Actdvltk=
As m ,uhmd of pcxmi tied by lair, we may disclose prdt ad health infamatiort about you to a public It Idt
ruthmity, for example, to report dl,ease, injury, or Vital et*eatta such as dotal,,
7. For Health tyversiglit,activities:
we may disclose your prottxnod heath infixoratiost to a bealth-oversight ;Iency such asp a prolctlem and advocacy
agency, or to other agencies responsible ft monitoring the health care system for sxch purposes as repo *,% or
invcstigation of unusual iacide ms or to ensure that we am in eotttplimct- with applicahle state and federal tares and
reguleticas, inch ding civil rights haves.
F. To Coroners. ?riedicsl Esaaiirrsn, F'uaurral I?tltretars,+iirrgan Psoeu?rrrpent (?rgaaluretiotu or'flsrttr t3atslts
We may disclose your protected bealth h%forma on to a comae or nsedical examiner for cite purpose of ideiatitill; a
decensod individual or to deterniua the came of death. W c may also disclose your protested stealth ialarmtttioa to a
funeral director for the purpate* of cetryring oyit your wisbes ancpor for ;he f icral arwor to ptrfirm hisficr
necessary ditties.
If you am are organ donor, we may disclose your protected hCAM inIbmatiott to tho organization that'gill Isar dlt
your organ, eyt or time donation for theptuposea of facil sng your otsp;.i or tissue doetrtion or transplantation-
9. For Research Purposes:
We may disclose your protected hWth information for research pwptlset withM your autbojzatic, ocly when a
privacy bed has approved the resco h project We -nay up or &close your prod hCL.M nrararattm to
indivitltt3ls preparing to conduct en approved research project in order to assist stab a,div deals in itf"fyina
perser,s to be included Le for tesesrd, project. Re.trchers identifying persons :obi included in the researdt projeet
oill not be permitted to rernovo protected heath hsform don frame our control. If it tuxoocs rneccesan to use or
disclose inff'armution about you that eouW be used to idmt* you by ngme, wt will obtain your %witim ariorhasm
before perm using the researcher to 33-e your information. Ilrse mb as will ix respired to sign a CmfideaAti uy and
Peron-DWoswe Agnteh eru form beibm being pmtaitied act= to prwmtrA heasah inioromtiet fox resswch
purposes. A sample copy of this ngrmn,ent may be obtaiusd fim our business office.
1. Ia. To Avtrt a Striew Threat to Fitt or Safi:.
We may disclow your protected health infoamatiort to avoid a serious drreat to Your health or safety or to the bcaith
or safety of others. When such t sclosare is necessary, infomation will only be released to those law enfbroemerit
agencies or individuals who have the nhility or nuti,ority to prevent or lessen tl,e lbreat of harm.
t 1. For 3udicisl or AdmlaWratlve freceedbgs.
We may disclose protected health infortanation about you in the course of a Judicial or a*niaibVat:-,4e proeeedir_g, in
s,;cordvace with our legal obligations. "
Privacy Ncniec 3 ;
30
Preen tiarirr
12. To Low Eatorcemeat:
We may disclose protected health information about you to a law enforcement official for certain lava enforcement
purposes. For example, we may report certain types of injuries as required bylaw, assist law enforcement to locate
someone such as a fugitive or material witness, or make a report concerning a crime or suspected criminal conduct
13. 1sStnot's`
if you are an unemancipated minor as defined under state law, there may be cireurnstances in which we disclose
protected health information about you to a parent. gt?ardlan, or other person acting in loco Pnreruls, in nccordasue
with our legal and ethical responsibilities.
14. FxrcoW
If you are s parent of Vt unermaccipt ted minor, and are acting as the minces pormal representative, vie may
disclose protected health informxion about your child to you under certain circummuces. For example, if wa are
i legally required to Main your consent as your child's persorual representative in order for your child to receive care
] or services from us, we may disclose protected health information abo•,?t },our child to you. In sorne circumstances.
we may not disclose protected health information about an une naatcipatod minor to you. For example, if your child
is legally Autt ori7.ed to vbt3k ;avim (without separate caeca kern you), mad does not request that you be treated'
as his or hzr pcrsonll repres.-satztiva, we may not be regtt,,, eit to disclose proteetad health information about your
child to you -,%*bort your ebild's wrnen audwrization.
13. To Personal elcr3retet*extl,es:
if you a m an adult or wiancipated minor, we may disclose prolaxcd health intimation about you to a persoaal
reloresenstiive autlac ized to act on yotr behalf in nrslting decisions about your health care,
16. F"ar Specific Goveranitut Fuecttens:
Ei
i tiIc may disclose protected bcasllh information about you For etemiti speeialind government fanctim?s, as autiicrized
by law. Amorg these functions ate the following mihbrv, cu.mmvd deteminatica ofyewaris beoefar, natioaal
security :end intel3igence aiAivi:ier protection of the PresWal and o(IM efcists; and thehert#tlt, safety, and security
orcorrettionul ins ituticns.
t7. Far Workers' Compensatiou
We ,nay disclose protected health_in1brmatiot about you for ptnprim fainted to workers' compensation, a5 requW
and authorized by law.
vl. Your Ftightrs ltegaming Your Protacted Hearth ttrfortratlon
you have the following rights concerning die use or disclosure of your protected health information that we create of that we
may maintain about you:
1. To Request itrstrl ems on Uses amd reap of Yovr Protected Health Fnl'ormarlon:
You have the rigbtm rn. ucst :hat we limit how use cK disclose your protecte health isfomoatioo fate treatment.
M-Ment or health cart opc _tions. Yvi also have dw right to requcu a limit oil the protc:ct_d health information we
disclose about you to scmevne who is involved in our care or tax payment for your cure or services. For ample,
you could request that we not disclose to fasnily members or 1'rencfs information nbout a medical treatment you
received.
Should you wish s restriction placed on the use and disclosure of your proicct*d health information, you ma-=t
subunit such request in writing. Such request should be submitted using our Rearrest to Restrict the Use turd
Disclosure of Protected Health hformation form. our contact in ration for purposes of malting such a itquest is
j listed an the last page of Ibis do=cument.
We are not required to agree to your restr3edou regaiesi. You will be informed if we decline your request. Irwe
accept your request, we will comply with your request not to release such information unless the information is
nwded to provide emer cncy care or treatment to you.
Privacy NaFce
31
Priwrcy Abike
2. The R*Nt to Inspect and Copy Your tletilth and BM ft Records:
You have the right to inspect and copy your protected health isfonaatlnn, such as your prescription and billing
records. In order to inspect and/or copy your protected health information, you must subunit a written request to us.
if you request a copy of your pracription or billing informaios or other records, we may charge you a reasonable
fee for the paper, labor, mailing, and/or retrieval cons involved in filing your requests. We will provide you with
information eonacernina the cost of copying your protected health information prior to performing such serAce.
Such requests should be submitted on our Request f x, lnspecdoWCopy of P?otertrd Aleakh Iq(ormation corm. out
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 Fall provide you with written notice of our reasons of the dial and
your ri.Ats for requesting* review of the denial. if any. In the event of a review, we will "Itet a licensed healthcare
} professional not involved in the original denial process to review your rawest and OUT rc :MS fur denial. We will
r abide by the reviturr's decision oonctming your inspectiou/copy requests. Your denial miew rmlao'st should be
1 submitted on our Denial of lrrsyecdon/C`opy ef Proaected Health I f+t lorrr form, tropes of these forma are
w ai iable from zhc comW person :isitsd on inn; last page of this document.
The night to Amtnd or Correct Your Prottcttd With iaformati"
Yotn have the riot to request tbst your protected health information be amended cc cotmeted if you have reason to
believe that certain information is incomplete or in=Tect You Nave the right to make such requests of us for as
long as we mair.win/raoin yrrnr prc,Aeeted bear ioferzaation. Your raluesls toast be tab wlt zi so us in wi,iting. We
will respond witbin sixty (60) days of recehing the wfitwn request, unlcm an extension is nwxwsry, in which con
you will be notified, and receive a response to your request A*in ninety (90) days. If we approve your request, we
i :jiff main s+ur'ti am sdmat lcArrcctir?ns ind nol:ify :hose with a need to know of tauclt amp dmcntslcorroctions.
We may deny your rsatarst ik
a. Your,rcqucst is not submitted im earthing;
b Your written requctt does not contain aremoat to support your request;
e. The infotntaticrt Aras not treated by us, artless the pert or amity that created the :nformadoa is no lornea
available to make tbs ameadmcmq
d It is no: a ;art of the prttctteti health infonnalion kept by acs;
to. it is not port of the infonnstiots which you wntuld be permitted to inspect and copy, andAw
£ The information is already accurate and complete.
if y it request is denied, m will provide you with a written notification of the reason(s) of such denial and your
rights to have the request, the dodal, rmd any written response (of'rea +iabk length) ;Vu may lave relative to the
informmict, and denial process Wended to your protocted health informatiou_
'Your ameDc cat/xrrecti;x request should be submittt d one our fear st for Araexbrrare<N' tut of mlecasd
Heal* 11,1, nrarca ial form. Copies of these forces art available from oar. business office- Ovir contact int-fr idlon for
the purpose of tanking such a request is listed on the last pogo of this document
k The Right to Request Confidential Communications:
You 3. sve the right :o request that we communicate errith you gout your health matters is a certain way or at a
cot sin losotion.: or example, you may request that we not send any protected hc&h information to you at a health
care kdlity, but instead and oot municatiorn for you to a residential c!ddress of Pon*. Office Box. We Vsall agree to
your repast as long es, it is reasoaable for us to do so.
Year may submit ynsr regw-sts on our ReTuest for Rtsbiction ofCoVlAn:icl Co tadaas form. Copies of
these forms are available from the contact pawn listed on the last page of this vocnatcnt. our omu ct inkWmaliobt
is listed on the last page of this document.
S. The Rl?i to R:talatesr ant Aceoaa€rting ot'ftlscl?aarts crf Prarteettd II#e?ltb Inform?at:
You have the right to request that we provide you with a listing of certain discicaures of your protected hash
information that we have made over a specified ;period o time- This mccoanting will not include auty information w;;
have made for the purposes of trantment, payment, or health care operations or in crmntion released to you, your
Pri4a- Not=
32
P.jva_.v {'arse
family or friends for notification purposes, disclosures made for national security purposes or to certain law
enforcement officials, incidental disclosures, disclosures made as part of a limited data set (for use in research.
public health, etc.}, or any disclosures made pursuant to your authorization.
Your request must be submitted to us in writing and must indicate the time period for which you wish the
information (egg., May 1.2003 through August 31, 2003). Your request way not include releases for mom than s.%%
(6) years prior to the deft of your xgtiest and may not include releases prior to April 14, 2003. Your request must
indicate in what form (e.g.. lyrlated copy or email) you wish to receive this information. We will respond to your
regaeot with sixty (60) days of the necc pt of your written mquest. Should additional time be needed to reply, you
will b-: so cotified. However, in no cut will such extension exoead thirty (30) days. The first acemnifing you
request during a twelve (12) Liomb period vall be face. Them may be a reasonable fee for addhional requests during
the t"dve (12) inenth period. We vnll notify you of the cost involved and you may choose to withdraw or modify
your regww at that tints butte arty costs are incurred.
You may submit your requests tut Our Rreven for an Acrouni ft of Disclosures of Protected tEealtii Infortirrrriort
farm available from our business office. 0<tr contact information is listed on the last page of this document.
The Rlgkt to ivt a Pager Cep,v of This notice:
YD- have the tip to rNttvt: a paper coci f of this notice even though you may lie agrevr to receive an elexxrosic
copy of this nor= You may r quest a paper ttol7y. of this notice at ar? ume or you m:+y obuirt a copy of this
inforrnadon fruit website (as applicable}. Out tact k1brmatiew is listed on the last page of this document.
Y1. Mm to File a Cotnphiat About Our Prlvwy Pnocllaw
if you have reason to balievt that W 11ave violzied your lbivacy rights or cur Pivac; policies mad procedures, or if yotr
d'isagrre with a decisiod the trade corioe iitag ac= to your p Vx-.wd beat information, YW have the right to file a
cornalaint wit, us or the Secretwxy of 11:c U.S. Depalrtm of of Health &nd Hum ma Services. You wrill trot beretalimed against
for filing a soanplaint.
You may submit yatir complaint on our Privrscy Pi-actices Coorplafist form available from our business office. D1;r ccntrtst
i:ifirmation is listed on the lost page oftllis document.
Privacy Notice
33
Prnuc} ,V0&e
CC N'tINLAING CARE RX NOTICE i'WACY pItJ1.G71CES
Record of Acktxr?i 3.-re u =Iz FaM Effort to Obtain ArcMw w dg?t
3 ?. ? ^.4
Name of (Rcsiden /Paticatj: hate:
Effective Date of This rrwuy Retke°A 14,200
Cvntuct Infor mAtion for Ques6aris, Complaints or` Requests a Yctar Heatth Information
Should you have any questions concerning our p6, n- pcaajce& obtaining a copy of oar P&4acy notim rcr ing
restrictions out the release of you infort n, revoking &I atiWxba*4 atn=drrtg or eore Ming your pmte€ted health
infor gim obukdag tin acoommft of our disclosures of }•ocr prntemed health infnrma608, 7r4jt>esting imam or
cop} ing of your medical in3rs vWjon, ring tbat ate = e infrXm3600 abutrt )I= heath waft is in a Certain
vs ., Ming cntuplaim or any otber eon you may have reWive to our pm-acq pnr-tx, please cmwct:
Brian `0.5twaney Chid Comobwe Oftar
5771 AlkAtown Blvd. Suite 202, Hasrisburt, PA 17112
Tel: 717-813-1950 &L 4, Fes: 7174It1-M2
bsiwxIley o`rnrs.arg
Ia" ycva wsir yov, may rlso flit s complahi with the Seatt ar of tht U.S. Dqubnat of Hatlih W Humeri Service S Y
,may mail ycnrr complaint to U, S. Dcpmnent of lieaitlt od fluaw Scrvioes„ 200 I? a= Avcnze, SM.. VlnshhWM
DC 20201: or yon mny call (202) 61 Q-0257 of 14X7.696-6775 (toll r at you. mall log on to the kwmi afttsk
AtkAerwlr6gaw-ut I Good Faith ENV to Obtain Aciiaat W*d&mcut (rhed OM oft 1"ollawhw
(I : Wn Im abolT Re UPwimi and I certify that I r=ived a copy of L e Cottmira nig Care Rx's Privacy Notiac acrd that i
have had an opponwity to rwsew ibis dccunw t and ask guostio ns to assist rite in auu asrt my rights t e'to the
prouLlien of my health ir-funwtiarr_ I am mdsftd with the wgdanations pfd to sm and I au confident that
Coutvarirsg Care Rx is oomnfstral u "=ft my health iukrrag?
Date _ Sigrriftre;
Printed Nam:
(? 1 ce"i3y thtst I ant tare angwrized representative of nbmti nww Rcsi+:icrn/atfent, arsl that I have received the Privacy
?3otIce on be6radf of this ux vsir l wd that CotVnuing Care ft provided me with an opp3m ity to mvicw this
domm=j and ash quesda is to aWst sra in umdrrswrdinS the pet=L's privacy sights. J am satis&-A with the
proviiW to me and I ant cwff*t0 that ft abcyr-mmcd entity is cormVitted to pro tg Iea1tl)
infionr*ion. L. fI n
i
Date: uVattite of pepresw u '2: _
Printed Name. M I
to .Isxii ril l:
Relatiott94
Above*
I I I.-- . t tby iw. i trams a zv4 f effort to obtain the aclcrawir of thre
lrogdad/patientj or tu&lw pal tgpt=tztive thin hdshe had retxsved a CC7j of the Prix y NO of
identified
continuing Care Rx, but Baas unable to obtain stich PdmvwWvoer t for :,4c fallowing reaacrt(s):
I jpwwcnvpwjadj or pemoaal restive :reined to sign
1 I or pmozw neparratn M VMS uwvailaNe to sign.
Date: Sigrultsre/Cithe_
hix ay Notice
34
e
iM
CNl1
OF GOD
HOME
"Committed to Caring"
PODIATRY SERVICES
I request tftat payment of eAcrizad Medicare 'Fits be made either to myse, or on my behalf,
Dr. tiVjaiam Pulig for any services furnished me by that physician. I whoriza any her of n :a1 inkmation
about ms to release to the Health Care Financing Adrninistrafon and its agents, any Information need to
daterrme these benefts payable far related series:
1
XYes, I have accepted Dr. W l n Pul as mypQdiatry care physician
No, I decline offered podiatry care physician for my podiatry cage
t
y1Wsx?--n n*!9 sue)
(Reside t Name)
J„r?er
in'a
(Fate F epresengtive)
35
CNUH
OF GOD
HOME
Tommined to Caring"
Privacy Act Sta nentMealthcare Records
This form provides you the advice required by the Privacy Act of 1934.
This form is not a consent force to release or use healthcare information pertaining to you.
Acr#*Ity for ooiecti, of information including Social Security Plumber (SSN)
Sections 1319(f),1919 (b)(3y,P), and 1854 of the Steal Security Act
SkiIW nursing facilities for Medicare and Medicaid are required to cor t comprettenstKle, accurate,
standardized, and reprvducibie assessments of each residents functional wpacity and health status. As of
June 22, 1998 all skilled nursing and numing Wiltiees are required to establish a database of resident
assessment information and to e!ectror;kalty trmsmit this information to the State. The State is then
required to transmit the data to the fedml Central Office Minimum Data Set (lutaS) repository of the Health
Care Financing Administration.
This data is protected under the requirements of the Few Privacy Art of 1974 and the MDS Long Tarim
Care ST,>tem of Records.
2. Principal purposes for which inf tion is intwded to be used
The information still be t i to tact changes in health aid W60nal std over tine for purposes of
evaluating and improving Me quality of care provided by nursing homes that par$eipatd in medicare or
Madicaid. Submission of mDS information may also be rosary for ft nursing f'omm to receive
reimbur-mint for Medicare scivices.
3. Routine Uses
The prfmwy use of his information is to aid in the administration of dm survey and certific ion of
Medicare/Medicaid long-term cen' facilities and th improve the effectiveness and quality of cam given in
Mose facilities. This system vAll also support regulatory, reimbursement, policy, and research f mctions.
This system will collect the minimum amount of personal data needed to accomplish its stated purpoe.
36
Privacy Act Statement-Healthcare Records (continued)
The information collected v ff 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 discbsed, under specific circumstances
tc: (1) a congressional office from the fecord of an indiAlual in response to an inquiry from the
congressional made at the request of that vidual; (2) the Federal Bureau of Census; (3) the Federal
Department of Justice; (4) an individual or organ for a research, evaluation, or epidemiological project
;elated to the prevention of disease of disat>+1ty or the restoration of health; (5) contractors wort frig for HCFA
tc carry out Medicare/Medicaid functions, cx ng or analyzing data or to detect fraud or abuse; (6) an
agency of a State government for purposes of iittk evaluating andbr assessing overall or agg"ate
cost, effectiveness, and!or quality of health care serves provided in the State; (7) another Federal agency
to fulfill a requirement of a Federal statute that implernants a hea h beWts program funded in whole or in
part Ath Federal funds or to detect fraud or aiwse; (6) Peer Review Organizations to per form 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 abu under spe fiic conditions.
4. Whether disclosure is mandatory or voiuntary and affect on individuial of not providing inbrrr tion
For nursing home residents riding in a cartiW Med!WrWM8&Sd nursing facility the requested
in€ormatloni is mandatory because of the need ;o assess the effixtNeness and quafity of ire gig in
certified facilities and to ass the appropriateness of pwMed services. If a nursing hwe does not submit
the required data it cannot be reimbursed for any Medinarelt mid services.
NO*rE: Providers may request to have tha Resident or fair Rgxasontative sign a copy of this notice as a
means to document ihat notice was provided. Signature is NOT required. If the Residenl or their
Representative agrees to sign the form it merely acWMedgas that they have been adviser,' of the foregoing
information. Residents or L heir Representative rrvrst be supplies vAih a copy of the notice. This notice may be
included in the admission ;racket for all now rtursthg horr* admissions.
I (we) a&..novrledge receipt o the Nivacy Act Statement - Healthcare Records
(Date)
(Re9d le P")
h
(Resident dame)
VA?,,-9,?
(FaMty
-47
46 Aah'?
f y ,r
CHLKH
OF GOD
HOME
-Committed to Caring"
Pate Room Policy Nursing
Policy: It is the policy of the Church of God Home that provisions shaft be aade for isolating a resident
in a single room whenever their medical condition requires isolation.
Pur : To ensure that the resident receives the most suitable protedron bible.
Procedurre
1. 1-he one private nur3ing room in this facility may be used as a regular prvatelsingie room
until the xacilit 's ne or iisolation room mss. This room is identifiW as Room 118
Fasih Wing.
2. Any resident using rn 118rnuu ree on nis on that they will move out of the room
to a sem?rivate room if the f GId ury s to use it.
3. When a rid for an isolation room sises ar:d a sernkXivatoo room is Mt ayaMle at
Church of God biome, the resident occupying the private room M# be tray rred as soon
as possible tsmpor-Ay ;o another loft/-term care Wity until a serni private room becomes
ayBilabia at the Church of God Home. This individual will lher be retumad to the private
room when it again becomes available.
#. Individuals inle sted in eccupy'ng a private foam shook make their Interest krmn on
admission to ttie Director of Admissions or their Social Worker at anytirm.
8. The. Director of Admissions will maintain a list of thosa residents interested in the pmale
room. Such resident will be offered the private room, wfien avatiable, tad on beir initial
admission date to'uha C-?um h of Gov Home, regardt°ss of titek level of care or the dais they
pl i their name on flhe waiting list.
6. When not in an isolaton need situation, a resident in the private roam must be of private
par otatus. If ne Icnger ably to cover the monthly bill, such resident wiff be asked to
rebate info a saani-private roonr as soon. as an appro*te ova be=, es evade at the
Church of God Hon .
()
Y, . I Z
(Red ,? . .sMe Patty)
Aw?--)-
(Reside'nMam-e)
(FadrAy Represen6
38
OF GOD
HOME
"Committed to Caring"
Therapy
Church of God Nome has arranged for Genesis Rehabilitolion Services, a professional, full-sue therapy
company, to provide physical, occupational, and speech Urapy services. The : seMm will be provided only
when the Residents physician orders hem, and when these services are nemssary to attain or maintain the
Residents hlg. est practica a physical, menu and psychosocial well being. While the payment of charges for
therapy services is the res ibiliity of the resident, insurance will usually pay for such sereices. It the resident
has kledime Pet B coverage, medicare Past 6 will pay for 80% of the therapy charges. The balance of the
may be pok! by the Resident's supplemental insurance. In the event therapy services are not covered, the
Res dent will be billed pjvately. Residents should reAew the coverage for therapy under their plan, and, if
necessary, cai the insurance company. Residents 1 Responsible Pady may contact our Business Office viah
questions related to Uierapy bong.
w
T? h!1! n o tha- pro 'r ion of therapy servius far
(the Rodent).
as ordered by Resident's p ' and deerraed necessary to atisirt or iraWain ft ht hest practicable physical,
rnental and psychosoc;al welk)eing. The undersigned understands that r{o guarantee or assurance has been
made as to any result that may be obtained from the Resident's treatment. The undersigned authorizes Church
of Cad home, Genesis Rehabilitation SerAces, and the Resictenl's teeth g or cmisulting physsicians In release
necessary reams nwied for the pro fision of therapy serAces or for payment.
s 14 - L
Pte)
n
(Resfds ditP w1W Perry)
J?, d. .
(Residegl Name)_ .?
(FacUfta Repres ntabve)
39
I' Vaccinations
Ii
)what Is Oftenza (Also Caftsd Fh4?
The flu is a coiftakpwts respirefnry lie caused by kdLm za viruses. ft can cause mild to savers WNW, and
at autos can leret to death. The best vray to prevent the flu Is by getting a flu vaccinsdon each yeas.
Every year In ft Untied States, on average
= 5% to of Ute poputellom qft the Err,
mare #han 200.03 p-opla are hospileflud born flu cot P*A*mK and
s about 36,0 {# paWla die &a Vin,
Some people. sucli as older people, young ch cinsn, and peWa with wrhM heats condflions (retell as
zsthma, ut'+rsbehma, or heeri dlseste), ere at ItO rktk for 1st Ru crxr+p5 a bo res.
ems or Mul
Synrtt&xrra of flu eiaKke
tower (usually htgh) . twiny or stu fy nose
a the . rriuscle ac.Ites
ev-ctreme t'?drueies Stomach synrplorne, such as name,
&I oough vorrhinp. and rrfrea, aka can occur but
• sate throd are more corrrrrton in ctd'fran than adults
Compiicaedonx of Flu
CorrlplicAorm of fkt can Includs barest _ ommwordear w&c4ons, moue K1Sectiom dahydrstion, t
womanirrg of chronic m.^-dW condfZbns mxb as cortgairdim heart Mum, asthma, or motes.
i
H" Flu Spreads
! Flu virusas apread rW,nk r b=n turn to perearr thmughpou*rrg or aneezN of people wMh fnfluenze.
Someflmes people may bet orm Inkdad by tuuchbtg sorsmft g with flat viruses on It and then OICift their
nxauth or owe. Wat hedttry odufte may be sine to h-Asci othm begs t day boo re syrrTAorrrs ate velop
rend up to 5 dayta 1r(tltr becornfrtg SO- That mwatts dial you m" ba ibla, to pss our tlia flu to someonia
i
else t>efGre you klrovr you are sick art well sa ;nhAs you are W
Primenttng So*oonal Flu, Gat Vweina led
= Ths: a beg wny to prev-nt ifre flu is to get a flu veccinstion each VwL There sere bm typssof vwdnez
r-ra "flu shot -an insctlvuted vaccine (conialning kMncl %U$) M la q%mn taints neadte. The flu
shot Is appluved for use in peopI3 B months of l;e end older, incudt{ug h tty people and people
with chror is rnmhcol cortdrons
Pa 1 of 3
DEPARTMENT OF HIMAL7tt AND HUPIAN SERVICES
CENTERS rme 018"i.E. CONTROL AND PArtVCNTICN
xAFXft-HwALTHICN• "EOPLC'
44
Key Fates Ab%tt5 ia) bAL (Flu)
The nas"pray flu vaccine - a vaccine made with fare, weakened flu viruses that do not cause the
flu (sometirrres called LAN for'Live Attenuated Influenza Vaccinel. LAN is approved for use in
healthy' people 2-49 years of age who are not pregnant
About two weeks after vaccination, antlbodles develop that protect against influenza virus infection. Flu
vaccines will not protect against flu-Ilke illnesses caused by non-Influenza viruses.
When to Get Vaccinaltd
Yearly flu vaccinztion shouk3 begin in September orak INS vary Is ave11116ie and continue th"r>gfnout
the intiuer>+ta sas sort, into Decx?, Jsrajery, and beyond. T'ttik It beceu* tie tbrstq, and dirrattitrrt
of stare m seawne we (y. While InSm2a *Atbwatks can happen set earty es Cklolbar, OxW of ttre
tints etiiuanza actiudy peeys in JtaIUM or Tatar.
Who Should (lust tl cinatsd?
In Viral. anyone who vm* to red= tltldr ctm = of I;I to tg the iltt can pet mod. Hinvaver, cetla h
people Mould gd vacaniged each yeses eMw becalm they are at high risk of havkQ serfs flu-rdt&teii
c ications or bade they five w Ph or cage for high risk puns, t *li to s ne wtmm vaccine suppft_
are knifed or delayed, the Advisory Corrimbee an Irriffmizagon Preens (ACID) matcas mmmoMMM
aModn r prim* arcuos for yacchaft.
People who should od vaccinated each yew are:
1. at M& slate for compOcabore from the M4 bmkxrtg;
• ChCdrun aged B nnonitxs tu.Ui their 6th hird-Way,
¦ PregnBnlwornen,
PeopW 50 years of age and older,
• Poch of aV age with certain chrorrk rated com ftris, and
Pile who Iva in rium tg horrin and other hang-terra tyre fades.
2 Peopk who live Yfth or care for these at high risk for comps train Sul inciudirg:
« Kors?tofd cottSrrc? o; persc+ts at high ?k for c+or2rtrm 6anl?e Att (toe ?+ej,
• HQ`M tratd corrtacie Rid out of )MM mim*jers of rh ea tabs >n B MM ft of sail (these children
am too yaM to be tad}, and
r Hse 1 care uKir1 s.
3. Chtldran aged 0 months tip to their'ie Wr'dtday
A. Anyona who wants to decrease their rmk of irAtienza.
Use of 1:11e Nasal Spray Flu Ne: curs
V11--dM On wifIi the rra6akP7.: flu vaccine Is an option tarheeW p 248yms of age vac ttr
prow,ramt, even hesi y persons -'-f1W NO or cers far awa In a t* tic gip. The one aception is
heaft poarts who, care for po7 sons wlth taalrs * weWwned irrrrluna ryeterrm who require a protected
anvii,Onma nt, trey healthy persws should go Me lneclivated yr echm
2ot'3
DEPARTMENT OF HEALTH AND HUMAN :SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTIOM
SAFER - FrRA LTHIER - PCOPLri
41
Who $ZXKdd "6s Vaccinated
Some people should not be vaccinated without first consuttbg a physician. They include:
• People who hwe a,sevem aNeW to chicken eggs.
People VAW have had a severs tssction to an irihtsnaa vacclMlon ti the past.
Peppin who develcipwd wIft 6 weeks of geifp an nkwm vaccine
Ctp .ire i has fm a mwAbs of age (ice vacdne in not approved for use In this age gaup).
• People who have a modwate or swere IGneas with a fever shoiddvraltto get vaccinated until their
symptwm tetten_
if you have quell ws about vvltether you should get a lu vaccine, co ug yw hsaitht care pravidar.
{ For mom about Pvmtrtinp the ihr, ere the Wowhv:
. Kw F About Seasonal Flu Vaoclne
Gb Foam Hati t tat Pn?yettti
The Flu: A ai for Pare
" IiWW Indtt" patsatta witmdo not twe an undMft medico} cotdpion thei predisposes them to
ink caonrpowdo is.
f
f
For more InfotTrretiart, visit www.cdc.aavlflu, or call CD[ at
800-CDC-PWO (EMIsh and Spanish) or 888-232-6348 (TTY).
POW 3of3
DIMPARTMENT fiVI HEALTES AHD HUMAN SERVICSS
CENTERS MR btSRASE CONT"L A!-V PweVCNT?ON
5AFER rHKAeTNiER• PEOPLE"
42
PNEUMOC{JCCAL
? / A j"'?? ?' ? E
POLYSACCHARtdE Vla?V
WHAT YOU NEED TO KNOW
Mil MlR+4 IS aMa iMU ?Pt YM1a?Wl be! IM No %§11PAPS& Sa MR#In?MR
Why get vweitsted? 11vtt? sheat,ld get PPV?
Pneumococcal discm is a serious dimm that All adults 65 yeses of age or older.
ceuses much sidmess and death. In fact,
pueumococcal disease kills mare people in tine • Anyone over 2 yem of age who has a long-
united States each year than all OUNM vaccine- tee hearth problem mrch as:
preventable disesses combrined. Anyeac can get - heart disease
pnenmomecat disease. However, some peglt are - hung ebanse
at grentcr risk from the dimse T'l ese include - sickle cell disease
people 65 and older, the vary young, acid people - d abctca
with spcdd bualtlr pmblema arch ass alcoholtrm, - skohaii€n
heart or lung dkeet, kidney More, dish, MV - cis hosis
inf,-etka, or am tda types of cancm - ka%s of cerebrmpinal fluid
Pu mmococcal disease mn lead to serious
infections of the lungs (pneamaun alb The Wood
(bacteremiaaj, anal the cavmiug of the brAin
(wczingith). About I out of tray 20 people who
pet pnenmccoecal paeuumonis dies fi-m it, as do
about 2 people out of IG who get baztL?.* and 3
people out of 10wbo get amcniagitis. People With
the special health problems mentiamcd the are
even spore likely to dic fay the dieeae
Diems arch as peoiaallin were once cffeetlve in
uvat=3 these hkaCtwnh butt the tlracm teas
becme mote =62=t w then drags, making
treatment of pnmmo=zw infections nxwe
diTkult. This makes prcvcn&m of the di sc
through veccinnion even more important.
(2T Prnetrmacoccai paiys=harlde
vaccine (PPIa+}
The pueumteaccal pd aacchasride v ore (FM
paomm aspinst 23 types of pneumococcd
bacteria. Most healthy adults who ga the vaccine
develop protcction to metal or all of tluac mm
within 2 to 3 weeks of Seeing the shot. Veit' eld
people, childr n tinder Z years; of age; and people
with owe long-term €ihoesses ought cot respond
ffi wa Or at all.
Au+yorae ova 2 years of age who has a disease
or condidw that lowers the body's resisomcc
to infest oa, such as:
- Hmlgk&s disease
-lymphoma, la:nltemnisi
- ki&zy failure
- mnltip.ea M%yebms
aephrutic syndrome
JW iuftcction or AIDS
damaged spleen, or no spleen
- orgsm transplant
• Anytme over 2 years of age who is tacking any
drug or ties cat that lump the body`s
resistance to nkcnoa, such as:
- long-tam steroids
- certain cancer drugs
- radktion the apy
• Alokm Netives and ccrtaain Native Americen
Populations.
Pneumoal Polysaccharide
3
(41 How rraztty tfo s of PPV are
needed? Usually one dose of PPV is all that is needed.
However, under some circumstances a second dose may
be given.
1 second douas is recommended for those people aged
65 and older who Sm their first dose when they were
under, 65, df 5 or tncse yuatcs hive passed since tbat
dose.
A second rinse is also tacaramended far people oho:
- have a datisagod sp a or no spices
have sickle-cen dimstie
- have WV infection or AIDS
have amcm kakw,!a, lym0=n;, multiple mycbma
A have kidney f Win:
- Ism nrp`arvtic syrdmme
- have had an mpn or bone tnartt v trsnsplasut
• art =king judketlun that buses imrnwniry
(such as chernothe_*apy or bug-term it. iU)
Children 10 ycus add acrd youaber may get this
second dote 3 years alter the first doss Tlurae tinder
than 10 should ga it 5 pars alter the heat riche.
Other facts about gutting the
?" yatcclne
• Od u" se htalthy tduldr--n who c f= P ,-c ear
infiecdohs, sinus irfcrions, or other upper
fi rtespiruttr dismvz do not need to get PrI because
of t'hca cations.
• PPV mazy be lees eSeLtiVe in txft PMAC, "Tocial?y
those -with barer reziatAree to infection 3u¢ theca
people should still b t, vaetdnatad, bacture th_q arc
mom likely, to Dct seriously ill Erom pne urmcoccal
disease.
• Prdgsaeatg: Tha sa of PPY for psugp ma worsen
hm net yet bees Uudled. Tome is an cviil== that
the vseciac is ht l to aithrr the modur or tee
fetaa, het Vwpow women dKuM txfrtauh rr>th
their doctor before bek f vacciasted. Women vain
see u hig=h ride of pimmoovoccal dbcnsc Mould be
vaccinated bds rc becoming prep, if pwible,
6` What We the risks frm PPV1
PPV is a very safe v%cmne.
About had of those who get the vaccine have vary mild
side et m% such as redness at pain where the oho! is
given.
Lest than 1% develop a fever, muscle aches, or more
sever. local sections.
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 voccine.
Getting the disease is much more !My to muse
serious problems than getting the vaccine.
C What W there is a serious
reaction?
Vithttd shmAd I look tor?
• Severe allergic reaction (hives, difficulty breathing,
shock.
Wiset SIMI€d I der?
• Gall it doeM or get the perms to a doctor right
MYRYL
• your dwm what happened, the date wad time
it happened, and when the vaccination was gives,
Ask your .beta; :tutu., or health department to
tepoet the tactios by Fddr; a 1'aciae Adv=se Event
13tptttang Syam (VAERS) form
Or you an Me this report tl -iO the VAERS wtV
&heat w r€Qera.org, ar by calling 1-aoa-822-7%7,
VAERS Am mipo ode nee lxal ado=re.
tiaw can i learn more?
• Ask your doctot or aunt. They can give you the
"=I= pnUge insert or sunest other uanurcet of
inforuratiom
Will your local W stet heehh deP-anmenL
Cruet the Ceatw for DiTtow Control and
Prevention (CDC)
- Call 1-800,732-406 (1-W4- VTF0) or
- Visit the Hatbnal I umuairad" Program websire
at. TWA:d..g 4VRcciIM
!tat hR TOH M.' UP 09KALTO I4tlttCa asxha,ttf
CWfTZXN MH DISF M CD*" WL Xne Spa'vexvje *
Pseamoooav! Vkccine 11krM rien Swcmeat
44
4Mb?
(!? iU
iJ
F 000
E
°Commined to Caring"
Vaccinations
The Church of God Horn administers flu vaccine on an annual basis for all residents of our facility, Annually the
TrW nt Influenza Vaccine will be offered, odor to the beginning of flu sewn, for ail residents V ft provide
written authoriza themselves or by hisftw responsiMe party.
A resident cannot receive are Tri Valent Infkjeenza if they are allergic to eggs or products. Otherwise, the Tri-
Went IrMuenza has proven to be ger+erJy safe and eifecfhre. If you desire to receive the TrW•atent Influenza
vaccine and/or the pneumonia vaccine, please complete tyre auttri tian Wow..
? I do authorize that the Tri-Valent Inflteenza vaccins tie given annually per fac ilfty protood.
? No I do not wish to =Iva the Tri-Valent Influenza at any given drrL
? I have received literature i wkiing to the bens its of hs Td-Valest Influenza vaccine.
The Church of God !borne also offers a vaccine that provides fictive protection against the Pneurrcc=al form
of pre+limoinia. This vaccine will be available to ftse residents who de*e it and are rne&al#y eNii?le. ff you,
have any quests, you may discuss there with your personal Physician r the Church of God Nome physician
who ,"itors your care,
? I do authorize that the PneuhtococcA Pnetrnonia vaccine be given.
? Ao, I do not wish to receive the Pre~. mocoecal Pnsunrinia vaccine at any given time.
? I have receives litem. ture pertakiiag to the benefits of the Pneumo l Pneumonia Vaccine,
If %novm, please indicate the date when the vaccines listed below we WreoeW:
TdVafent In tenze va :
rpnarnr onle Vaccine:
Tetanus Vaccine:
(Date)
45
(Re*etM1wpom"e P")
4M?,
CHURCH
F GOD
HOME
"Committed to Curing"
Valuables
The Church of God' Herne desires to administer quality care for all of our residents, focusing on a nigh quality of
rife. We do want to awed any unfortunate situation that could result in any fhancial or emotional loss to
(?`residents and/or;am'illes. Cur Home has not tied many such losses, but when they happen, it is bNic.
'fo i ri pize the risk of loss, the Church of God Home recommences that residents have no more than five dollars
,g5.00} ls; any one tires in their possession or rooms, and keep no valuables, reA or intrths1c, in their Moms. By
*rling N k paper you acknowledge Wing informed of the Horne's recornawdetlons. Some people have wisely
substituted 'Vircons for diamonds and kept ttte wings. It is iha res ibirdy of itte resfident or the mponsib
party tr; h-4 items of value independently appraised and irmured, 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 Cod Home will
in ter each kiddent of loss or damage to determine; liability and assess depending on the facts anti
cI=tmst=es of each 'aide nt. The Church of God Nome shell be responsible for only such kx= or damages
as are affibuted by the He due to the negligence of the Horne.
/A/
(Date)
(i es d?n pomltse
i
t
(Rt N
V_-
(Facility ReprantatluP}
46
CHURCH OF GOD HOME, INC.
ADMISSION AND CARE AGREEMENT
THIS AGREEMW is made on this ?"day of 20_ , by and between the
Church of God Home, Inc., called the 'Facility,' a Pennsylvania n n 80h
Hanover Street ste, 7t d n var}ia, and called
"Resident' and ca d'Responsibie Party.
The Resident and the Responsible Party reaffirm that the information provided 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 plied .,for admission to the facility and the Facility has
aplxoved the Application for Acdrnissi . Therefore, the Facility and the Responsible Patty agree to the following
terms:
PRQVISION OF SE CES - The Facility %mill provide Resident with:
a. Skilled nursing care, i.e. professionally superb nurs:g care and related health services under a
plan of services regularly provWed under a plan of care supervised by lien ,ed peersonriel and, as
required by the Resident's medical condition, a ?M!h acuAties of daily living,
b. Acc=modations consistent with the level of cam provided to the Resident lnc?ucfing heat, air
conditioning, electrici'y, hot, and cold water.
c. Bed, bedding, blanket, laundered bed linens, trnwals, and washcloths.
d. Titres meats each clay except as c#wMse medically indicated.
e. ActiAty programs, Spiritual programs, and Social Serviced.
2. RECURRING CHARGES- In exchange V the above servers, the Resident shall pay the following
recurring charges:
s ?t
a. For skiitad nurslr?g care: doN per day.
3. SECURITY DEPOSIT - The Resident shall pay the fogcwing noiecuning charges:
a. , securihj deposit in the amount of ;hirty-ane (31) times The current drily rate for the level of
required by tote resident, X41 be billed after adr ion day. The mount of the security wit is
! No interest will be paid on the security deposit A security deposit Irv l not 4e charged to
rw to are receiving beiefis for ram and board provided by Medicare, until the Ma icars
benefit coneJudes. An applicart who is coavtrd by Medicaid is not required to pay a security
b. If Uie admission to Nursing 'Care is the result of a level of care chantge from Personal Csre, the
Rent will be billed tide difference men the two Security Deposit rate..
e. The security dawsit for private pay ras ts, after deductions for the pament of any ouLAanding
bills owed to the Facility, ,-Ail be reWded within thirty (30) days after the Resident's discharge or
death. Upon discharge or death the foL-Mng refuel policy wilfi l f0mved:
i. fir~.y (30) days - Private Pay
iJ, I- nety (90) days - Medicaicd
W. Thirty (30) days - Personal Cash Account
There,Mll be no other refunds, it the absence of an over payrment, under this Agreement.
a. MISCEL AMQLIS CAGES AND OUTSIDE SERVICES - Resident is responsible to pay for otiter
services provided by the Facility, which are not covered by the daily rate/charge. A list of such services
charges is attached to th+s Agreement on fe'Chart of Costs'
47
Adm In and care brae-wn contitund
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 hislher own physician or any other service provider so long as the physician
or other service provider is property licensed or registered under the law, and that all applicable government
nrles 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 serve
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,
optow.*-Ast, therapist, diagnostic or resting laboratory, pharmacist, pharmacy. hotel, or any other person,
facility or entity providing services or goods to or for fibs Resident, and for al drugs, meftirw, r=-dications,
pnarrnacautical supplies, corrective eye lenses, hearing aids, dentures, hair care, and outer personal items or
services for the Resident. Such fees and costs are not included in the Home's dailly rath. kharge.
5. ADMISSION -The Resident will be admitted, or a bed v II be reserved for Resident, beginning on
4- . A: pra~admi n cites will to trilled after admission, and r=uing
urges vrt ?airt to accrue as of the above date.
The ResiJerd may reserve an avaRrible bed by pafrrtg the daily rate for the bed reserved. fire daily rate
for thes reserved bed will continue to accrue and be payable until tha reservations terminated, even if
the Resklertt does not enter thz Home for w1hate }per reason, including illness, injury, incapacity or math.
6. PERK)DIC 81LL1NGS AND PAYMENT DUE DATE
a On the trst of each month, Residen v4 be biped the current daily rate for Residents current law of
care times the number of days in 3:e morsth. The bill is due and parable upon receipt A service
charge of ore and one-half (1 1/200 peroent rper month will be aged to smou€ is past due hi excess
of thirty (30) da'y's, and Resident, and it appaca a, Rasponsib.e Person or Guarantor is obligated to
pay any late charges.
b. i scallaneous charges (Wier to 'Chart of Costs' attached to dais A.grwnertt) such as hair care,
laundry, incontinency, supplies, etc., are a0 tirxral charges above the daily rate. These
miscellaneous charges viill be v1ded to, and included with, your monthly bill.
c. Pharmacy changes will be bille=d as a separate part of the FEdli y's rncmthly kill, and v0l require a
separate che&
d. Outside providers will btf directly and separ ly.
7. g;ANGES IN CHARGES- From tirne th time, Lea Faraiiy may ct-?w the arnount of its charges. In
addition, from time to time, the Facility may change how and when its changes are computer:!, bMW or
become dw. The Facility reserves the right to make any such changes at arty'lime. Viritten nom of
any such changes will be given to the Residentthir y (;g) days in advance of implenseniat+on, unlesstFie
chi is required eadiier under any federal or state law or assistarcks program.
8. "MEDICAFRF EDICAID' PROGRAM - The Facility participates in the medicare program ministered
pursuant to Title XVIII o f the Federal Social Security Act and the Med d (Medical Assistance)
Program administered pursuant to tie Pennsylvania state plan and Idle XIX of the Federal Social
SeCudty Act. However, the Facility reserves the right, to withdraw frorn the Madicare/P edica program
at any time in accordance with the lam.
48
Admission and Cwe Agreement continued
9. OBLIGATIONS O I SPON$IBLE 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 F. hsiblee Patty 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 ttae F ity for a period of
hospitalization, therapeutic leave, or any other team, other than the Resident's death, and N the
Resident is not eligible for, or removing medical assistance, the Responsible Party vrtll be contacted to
da". ine is the is to be held in reserve at the dimly rate. If the Resident or Responsible Party
elects not to reserve a bed, tl rtlhe Resident will be eligible for readmission upon the avellability of the
fist bed suiWe fbr the Residents level of care.
If the resident is riving nyxlical swist ce benefits and the Resklent leaves the Facility for a period'
of hospita tion or therapeutic have, the Resident's bed will be reserved for the aW)cable maximum
rivmbw of days paid for the reserved bed under the Medicaid (Medical As*tanoe) Program. 'rhe
cumnt bed resenrakn period Is fiften (15) hays for hospiWization, fifteen (15) days for therapeutic
leave for raWents receiving skflied nursing care, and thirty (30) days for ttrerapeutic leave for rpsidents
receWing nursing caP°. The bed reservation perM may be sutiect to change in accordance with any
changes in the Medicaid (Me al Assistance) Program. If the period of hospitakz n or therapeutic
leave end3 within the reservation perod under the Medced (Medical Assistance) Pmgrarn, the Redd rft
may return to the Facility. If the perm of hospitalization or therapeutic lea% exceeds the maximum
tin* for reservation of a bed under the PAedicatd (Medical Assistance) Program, the Resident must vet
Until a 31-table bed becomes available for readmission. The Resident is entitled to the first available bed
suitable for the President's leval of care if, at t?)e time of readmission, the Resident requires the servers
provided by the Nome.
Effec!Ne May 30, 2W8, fvfedicare requires that each resident/ responsible l ee their ch
with regard to a bed holtf if any nursing resident is hospitalized.
? Yes, I wotdd request a bed hold. I understand that I will be billed at the standard dally rate.
? No, I not urish to hold a bed in the event of a hospitalization. I understand that by doing
bed may no be avalables for readmission.
I o be determined at tame of hospitalMon.
11. REFUNDS - The security deposit for privy pay rerldents, after deductions for The pay nt of any
outstanding bills owed to the Facility, will be rem Athin thirty (30) clays a the Resident's
disd arge Facility or deadi. Residents receiving Medicaid vAll receive a refund, if any due, vAthin ninety
(90) days. Thera will be no otter refunds, in the agree of an oNsTa anent, under this Agreement.
12. PERSONAL FINANCES - The Resgent has the right to manage blether' personal funds. The Resident
is and will be responsible to provide hWmr persona funds. If the Readent elects, the rent may
designate, in wrifing, that the Facility hold and manage the Residents persona funds. If the Resdent
designa?es someone other than the Facility to manage hisftr persona funds, t Resident or
Responsible Pai`y shall notify the Facility promptly. The Resident is not required to make any
designation, ad' is responsible for his/her oven personal funds unless such designation is grade.
49
Adrr&-"on and Cara Agme+nerrt continues)
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 Horne, 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.
ABSE ItrE
13. TERIWTION, TRANSFER, DISCHARGE, € t NAVE OF
a. By the Resident: The Resident may terminate this Agreement upon Nrty (30) days written notice to
this Faality. If the Resident leaves the Faatity for any reason other than a medics emergency or
death, the Resident must give written notice to the Facility at least thirty (30) days in advance of `?e
departureltrdnsferldiscl a or termination of the Agreement. If advadte rwitten notice is not given
to U`w Facility, There. will be due to the Facility it's daily and ot,'rer changes then in effect for the
Resident's current level of care for the required thirty (30) day iutice period. The charge applies
whether or not the Resident remains at the Fa ility during the Dirty (30) day period,
b. By the Fac&Aw The Facility may terminate ttie Residents stay and tr a lsfer or disduirge the
Rena if:
L The transfer or discharge is necessary to meet to Re r1f3 vre?fare which cannot be met by
the Facility;
ii. The Residents health or condition has improved suttiently, that tips Resident no finger needs
the services provided by the Faciftj;
iii. The safety or health of individuals in the Facility is or otherwise would be endangered;
iv. The charges or other amounts due the Facility under this Agnaement have not bee, paid to the
r acility or treated as paid to the t=act qty on fhb Resident's behalf the Pennsylvania Medicaid
Prcgrern or Federal Medicare benefits under Title XVlli or
v. The facility uses to operate.
fie Fat, ity generaaly wt'rt notify the Rent and Respor% Party or if ,one, a family member of leget
representative of the Resident, if known to the Factifty, at feast: thirty (30) clays in ance of such a
transfer or discharge. l-lavever, in any case, described in subparagraph (1, CO) or (IN) above, or if tine
Resident has not reseed et the Facility for at least tfrirty (30) days, the Facility will give such erotic
before transfer or discharge as is practicable under ft circtstr ,cues.
50
NW'
Admission and Care Agreement continued
14. 1HRD PARTY PAYMENTS - The Rest may bs or may become eltible to receive financial
assistance, reimbursement or other benefits from third-patties, 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 ll?e Resident, the Resident/Responsible Party shall, at all times, operate fully with the
Facility and each third-p + payments. Cooperation includes, when requested, proving information,
signing and delivering documents, and having the Facility designated by the Social Security
Act istrat on as the Residents representative payee for receipt of Federal Social Security benefits or
any other gcy me mental assistance, reimbursement or benefits to the extent of all charges due the
Facility. The Resident irrevocebly authorizes the Facility to make claims and to take such other aciinns
as maybe necessary for the Fac ity's receipt of third-party payments. To the fullest extent permitted by
laws the Resident hereby assigns now or hereafter psynbte to the extent of all charges dire to tie
enti se and to ri over to the Facility any aymeft received from third-patties to the extent nary to
satisfy tie charges under this Agreement.
e5. PERSQNAL PROPERTY- The Resident/ Responsible Party is and will be responsible to furnish and
maintain clothirg, jwrelry, personal possessions, and other item of property. The f ty may limit tie
amount or type of property that ?)s Resident may keep at the Wfity If there is it tfiiclent space, or if
medically indicated or nacewary to protect the rights or %vfare of others. A3 nbn hiN Item of
value must be recorders on the resident's personal inventory located w h their medical record on the
day of admission or any day thereafter. The same is true if removing an item of v ie from t<he
re"nCs room. You are requested to see tfie age nurse / s worker r ,+ding resdent`s
personal property. li clothing needs lac ti, please Leave them at the nursing station,
laws and
13. RESPONSIB S OF RESIDENT- The Resident stag comply fufi with all governrn it tal
regulations, the provi arcs of this Agreement and the facillty s existing policies, rules and regulations
which may, from Berta to time, be altlared or amended.
17. MISCELLANEOUS PROVISIONS
a. The Resident and Responsible Party ackrrowWge that they are adult individuals and have read
and umfersta d tha L,=* of this Agreemertlw
o. The provisions of this Agreement shalt be governed by the rows of the Commonwealth of
Pennsilvania and shall by binding upon and inure; to the benefit of each of the undersigned
pules and their respective heirs, personal representatives, successors and mesa,
e. The vacs provisions of this Agreement stall be severable one from another. If any prom
of this Agreement is found by competent legal authority to be invalid, the other provisions shall
remain in lull force and effect as if the linvaid provision had not been part of this Agrewvnt.
51
AdrnisWon and Cars Agreement- conies t
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 charges in charges. Resident will be provided
thirty (30) days written notice of changes in charges and, if practicable, reasonable notice of any
modifications required by law.
(Date) (ResidentlResponsible Marty)
c.
f N
t
(Facdity Rwesentadve
52
RESIDENT / FAMILY GUIDE TO INLUIRIES AND INFORMATION
.r C
co H iQ N C
C w c* E N C M _ 01 ++ d
T 7E
cr
c
?
?
32 40
Y° Ua
0 a c°? s
??
v s ° 1E 2` c a m o
N
Inquires
m >D
x Ofl U ti0 O xQ
Change in Laundry
service x
Transport
Req? X X
Serial Hair Cane
Requests, Payment
Sahedulii ng X
Recent Care
I X
Resat Medic lon
X
Physician Questions
X
They C,:<us
,
Taking Residef m
Out of Facilify X
ChmVe in POA
Corot x
Address /Phone
Change In POA
.'? x
! Health insut
cards x
Religious Questions
x
Funeral amdorS
x
I Funeral Prson
f Sef*e x
Memorial Services
X
"The Orchards' at
marsh Run x
54
-Roil
PAD
Facility Wiling Address; 801 North Hanover Street
Carlisle, PA. 17013 wif NT
Fae Maim Tele?om : (717) 249-5322
FadI tX Admi or: ...............Susan Bower, NHA ................................................................ ext. 3085
Act?rlt#.: ? ..............Amy Fin, CTRS..............,.................................................. exL 3021
(Dirmtor of AcNties) -'
sushi . on Of n Sbaron Cramer (Didness Olfice t Henderson House) ..................... ext. 30321
(Sr. Bing AR Spedst Personal Cash Accounts)
E] .............. llk heke Shughaft (Businew Orlice I Henderson House)..................... ext. M5
t'rfg Spe+ast - MmW Assis nce) .r r . ,-
Care P : F ? .............. Lynne SI<allenbeTer, RN ( g, girl 14 days of Adm bn C.ext- 3033
(;vV&g A ment Coorurnator- RNAC) i t7_ -
Cb#A ln: p ............. Pssivr Brewey eons................................ ....................... ext. 3022
D arD j: p .............13wisy Weiser........ _ ................................................... ext. ;'
(WeGia of Dining SwA=)'
Hair rq ? ..............WR txdxt............................................................................ ext. 3003
pector of risk care)
t?dlcar ? .............aava Bsliz............ .. .................................................,..ext. 3.%1
(Nudq AdM?e fzssistar?t)
Nu it ...... bby Na?ttmn, R1M, ?N .....................................................+ext< 3015
............. ) M-11s ....................................
Pali Lo, all ..........
(#103
? .............Feb S?cu1 HO ( loo-102,117-12n") .............. I.......... I............ ext, 3010
p............. Lm I (t" Dc 1-215) . ............................................................... ext. 3024
p .............LcM't ,r,17-239)......... ............................................................ ex.,. .3U5
? ...............& Thumirta, LPM................................................................ e. t. 3112
(Pwmd Care ??drniri9stator), (dope, Peace and CCreekside Apt)
l lrrtna lt: . of resin x; 9le iv .............................. ...................... 1-600-875-.2270
social SerAc"; ............Erin Itlaf* MSW ........................................................... ('*xt. 3084 1
(Director of Social SwAoes)
? ..............E7ien Pms, MW..................................................... extt 3023
(Social worm
Thy lam.' ? ............. Genesis Rehabilitabon S rises ............................................. ext. 3017
i.
Volunteer gibe: ? .............Linda Waggoner ............. ....................................................... ext. 3028
3
(Director of Volunteers) E is
Physics - Telepl??: E'
/? ?? , 55
Checklist - Nursing Care
i. CG ETE/ COPY:
ADVANCED DIRECTIVES
-TAMBULANCE CARD
URCH OF GOD HOME, INC.
F AE SHEET. .
INSU, CARDS VERIFIED
r AFL
EMEitITAL
? RX
? OTHER
2. REVIEW AND IKFORM:
ADMISSIONI AND CARE AGREEMENT
ADMISSIONS POLICY
ADVANCE DIRECTIVE POLICY
AMBULANCE
CPART OF COSTS
COMPLAINT PROCEDURE
DELEGATION FORM
DEPLETED FUNDS
DIETARY SERVICES
DVD ACKNOWLEDGEMENT
GUEST ROOM
LEGAL RIGHTS COMPLIANCE
MEDICAID
MEDICARE
MISSIONNISION STATEMENT
NOS!-DISCRIMINATION STATEMENT
PERSONAL CASH ACCOUNT
PERSONAL LAUNDRY
-EIMNG-TERM. CARE INSURANCE POLICY
'I'A-RD
agWER OF ORIVEY
DICAL
"'SECURITY CARD
ACCINE INEOPUMATION FORM
p OTM
[ TO,BUSINESS OFFICE
COPIES TO DEPARTMENTS
RESIDENT
El?py TO RESPONSIBLE PARTY
PHARMACY AGREEMENT
PODIATRY
PRIVACY ACT STATEMENT
PRIVATE ROOM POLICY
PSYCHIATRIST
RESIDENT I FAMILY GUIDE
RESPIRATORY CARE
SMOKING POLICY
SPECIALIZED SERVICES
SPOUSAL RESOURCE ASSESSMENT
THERAPY SERVICES
TRANSPORTATION
UNDERSTANDING RESTR JNT USE
VALUABLES
WELCOINIE DIP.ECTORY
WELCOME LETTER
X-RAY
OTHER
I acknc edg9d that I have r ived the above inf don and have been al led the opportunity to ask
quesfions
_L
q Ii
sible Party)
(Date)
56
EXHIBIT 64c"
(TO COMPLAINT)
Notice i u: 9UUf 19b91y
CUMBERLAND CAO
33 WESTMINSTER DRIVE
CARLISLE, PA 17013-9976
Mail Date: 03114/2012
CHURCH OF GOD HOME
ATTN: BILLING
831 NORTH HANOVER STREET
CARLISLE, PA 17013-1599
pennsvtvania
DEpAIII'"MENT OF PUBLIC WELFARE
OFFICE OF INCOME MAINTENANCE
Record ID: 2110163127 Telephone: 1-800-269-0173
Notice ID. 9007195929
COMPASS: The fast and easy way to apply for benefits
DEAR CHURCH OF GOD HOME,
You have been designated to receive a copy of this notice on behalf of Ruth Aubin (850285141).
Please read further for details.
Which benefit? This is a summary of your benefits.
You can find more inforrnallon inside this letter
Medical Assistance You qualify for Medical Assistance starting July 01, 2011.
You qualify for payment of services in a Long Term Care
Long Term Care facility. You must make a monthly payment towards the
cost of Long Term Care benefits. You can find more
information Inside this letter about how we decided what
your payment will be.
If you have a disability and need this letter in large print or another format,
please call our helpline at 1-800-692-7462. TDD Services are available at
1-800-451-5886.
If you do not agree with our decision, you have the right to a Fair Hearing. To learn more about Fair
Hearings, read Your Right to Appeal and to a Fair Hearing.
Do you need legal help? You can get free legal help by visiting:
MIDPENN LEGAL SERVICES
at 401-405 LDUTHER STREET, CARLISLE, PA 17013 or by calling (717) 243-9400.
Rarnrd In- 91/171163197 Mail Data: 03/14/2012 Paae 1 of 8 PA m *9007195S12930000104*
Notice ID: 9007195929
-. Your Medical Assistance Benefits
(Lv-? Who qualifies?
Who qualifies? When? Which package? Prescriptions? Acewo
Number
RUTH Jul 01, 2011 - Oct 28, HCB04 Yes x 850285141
2011
You will get the benefits above until there is a change in your case.
RUTH: (07101/2011-10/28/2011) Inside this letter you can learn more about the income and deductions
we used to decide if you qualify.
Your Long Term Care Benefits
Who qualifies?
Who? When?
RUTH Jul 01, 2011
You will get the Long Term Care benefits shown above until there is a change in your case.
RUTH: (Starting 07/0112011) You qualify for Medical Assistance (MA) benefits in a Long-Term Care
(LTC) facility. The LTC facility will be sent an MA benefit card (PA ACCESS card) unless you were
given one before. You will need to pay the LTC facility a monthly payment towards your cost of care.
Details of this monthly payment towards your cost of care are found in the LTC section.
This is the law we used to make this decision: 55 Pa. Code §§ 141.81, 178.1, 181.1, 181.11, 181.452,
181.453
Record ID: 2110163127 Mail Date: 03/1412012 Paoe 2 of 8 PA 182
Notice I D: 9007195929
Mg How We Counted Your Income
Here are the amounts and limits that we used to decide if you qualify for benefits.
Your Long Term Care
We used this for: RUTH
07/0112011
Your total reported $3,332.50 j
Income
Income Available First $0.00
Month:
-Deductions i
• Personal Needs Allowance $45.00
=Payment Towards Your $3,287,50
Cost of Care
The Long Term Care facility will deduct the following medical expense(s) from your contribution
towards your Cost of Care. The Long Term Care facility may deduct additional medical: bills
including supplemental health Insurance premiums, provided they are verified.
Medical Expense
Deductions:
• Medicare Premium $75.50
• Other Insurance Premium $0.00
To learn more, see the eligibility handbooks at
http://www.dpw.state.pa.us/publications/polleyhandbooksandmanualsi index.htm
Dcnn/vi MI. 71!!119; 21?7 AAnit noia• n'AMAron1o, Done '^f Q Gs w> *0nn74nGt»n nnnn')nA*
EXHIBIT 66D"
(TO COMPLAINT)
RESIDENT STATEMENT FROM
CHURCH OF GOD HOME, INC
801 N HANOVER STREET
CARLISLE, PA 97013
717-249-5322
Statement Date Due Date ACCOUNT NUMBER
03/3112012 Upon Receipt 802839
AMOUNT PAID $
RUTH C AUSIN
do MICHAEL BLESS
22 SUMMITT PLACE
CEDAR HILL, TX 75104
.'omments
$0.00 $12,684.75
Daft I
Balance Forward
)7/01/11 - 07117/ i 1 Patient Liability
17/01/11 - 07/31/11 Room & Board
17/06/11 - 07106111 Wash & Set
17118/11 - 07/18/11 Wash Cream
17/27111 - 07127111 Wash & Set
17/31111 - 07/31/11 Laundry
17/31/11 - 07131/11 Finance Charges
18/01/11 - 08/17111 Patient Liability
6/01/11 - 08/31111 Room & Board
8/04/11 - 08104/11 Adult Wipes Refills
8/07/11- 08/07/11 Pullups - Medium
8116/11 - 08/16/11 Wash & Set
8125111 - 08/25111 Adult Wipes Refills
8/30/11 - =30111 Perm w/ Conditioner
8131/11 - 08/31/11 Laundry
9/01/11 - 09/17/11 Patient Liability
9101/11 - 09/30111 Room & Board
910211 1- 09/02/11 Wash Cream
9/02111- 09102/11 Pullups - Medium
9114/11 - 09114/11 Tint
9116/11 - 09/16111 Puilups - Medium
3/16/11 - 09/16/11 Adult Wipes Refills
9/28/11 - 09/28/11 Wash & Set
3/30/11 - 09/30111 Laundry
)/01/11 - 10/17/11 Patient Liability
)/01/11 - 10/27/11 Room & Board
Please make check payable to CHURCH OF GOD HOME, INC
Remit To:
CHURCH OF GOD HOME, INC
801 N HANOVERR STREET
CARLISLE, PA 17093
Please detach and return this portion with your remittance to the address above.
$o,ao $0.0o $283.05 $12,967.80
O„; F R,
Urj6
$30,300.99 $30,300.99
$3,242.00 $33,512.99
(31) $(249.00) $(7,719.0 $25,793.99
(1) $13.00 $(13.00) $25,780.99
(1) $5.36 $(5.36) $25,775.63
(1) $13.00 $(13.00) $25,762.63
(1) $33.75 $(33.75) $25,728.88
(1) $153.52 $(153.52) $25,575.36
$3,212.00 $28,787.36
(31) $(249.00) $(7,719.00) $21.068.36
(1) $2.88 $(2.88) $21,065.48
(1) $14.50 $(14.50) $21,050.98
(1) $13.00 $(13.00) $21,037.98
(1) $2.88 $(2.88) $21,,035.10
(1) $54.05 $(54.05) $20,981.05
(1) $33.75 $(33.75) $20,947.30
$3,212.00 $24,159.30
(30) $(249.00) $(7,470.00) $16,689.30
(1) $5.36 $(5.36) $16,683.94
(1) $14.50 $(14.50) $16,669.44
(1) $30.00 $(30.00) $16,639.44
(1) $14.50 $(14.50) $16,624.94
(1) $2.88 $(2=88) $16,622.06
(1) $13.00 $(13.00) $16,609.06
(1) $33.75 $(33.75) $16,575.31
$3,212.00 $19,787.31
(27) $(249.00) $(6,723.00) $13,064.31
AGILITY NAME RESIDENT NAME ACCOUNT NUMBER
;HURCH OF GOD HOMF INf 171 rrta r ei 121KI
ESIDE'NT STATEMENT FROM
CHURCH OF GOD HOME, INC
801 N HANOVER STREET
CARLISLE, PA 17013
7117-249-5322
RUTH C AUBIN
c/o MICHAEL BLESS
22 SUMMITT PLACE
CEDAR HILL, TX 75104
OiNe p?{.plfp?
S
10/05/11 -10/05/11 Aduit Wipe Tubs
10/13/11 - 10/13111 Pullups - Medium
10/13/11 - 10113/11 Adult Wipes Refills
0/19/11 - 10/19/11 Adult Wipes Refills
10119/11 - 10/19/11 Wash 8 Set
10/24/11 - 10/24/11 Puilups - Medium
0/26111 -10/26/11 Color rinse, set
0/28/11 - 10128/11 Laundry
DR* i
Units RAM ?
t ChwpW
rx_ y
(1) $4.07
$(4.07)
$13,060.24
(1) $14.50 $(14.60) $13046.74
(1) $2.88 $(2.88) $13,042.86
(1) $2.88 $(2.88) $13,039.98
(1) $13.00 $(13.00) $13,026.98
(1) $14.50 $(14.50) $13,012..48
(1) $14.20 $(14.20) $12,998.28
(1) $30.48 $(30.48) $12,967.80
TOTAL BALANCE DUE: $12,867.80
x'
Statement Date Due Date ACCOUNT NUMBER
03/31/2012 Upon Receipt 802839
.84
AMOUNT PAID $
Please make check payable to CHURCH OF GOD HOME, INC
Remit To:
CHURCH OF GOD HOME, INC
801 N HANNOVER STREET
CARLISLE, PA 17013
Please detach and return this portion with your remittance to the address above.
TY NAME RESIDENT NAME ACCOUNT NUMBER
,H OF GOD HOMF INC: Rt rrw r Al 1111M ennnnn
Ronny R Anderson
Sheriff
Jody S Smith
Chief Deputy
Richard W Stewart
Solicitor
SHERIFF'S OFFICE OF CUMBERLAND COUNTY
r Lru- t :
I'? -yF `ry? r rF
47
?yrqRO
• i E 1
Zf,117 JUL -3 A 6.23
,'UMBERL AO Go'ai NTY
Church of God Home, Inc.
. Case Number
vs.
Ruth Aubin 2012-3858
SHERIFF'S RETURN OF SERVICE
06/26/2012 Ronny R. Anderson, Sheriff, who being duly sworn according to law, states that on June 26, 2012 at 1951
hours, he was unable to serve a true copy of the within Complaint and Notice, upon the within named
defendant, to wit: Ruth Aubin. Deputies were advised Ruth Aubin is unable to accept service due to her
medical condition. Her Power of Attorney is her son Michael Bless, 22 Summit Road, Cedar Hill, Texas
75104.
SHERIFF COST: $43.00 SO ANSWERS,
June 28, 2012 RON R ANDERSON, SHERIFF
- cSIDENT STATEMENT FROM
CHURCH OF COD HOME, INC
801 N HANOVER STREET
CARLISLE, PA 17013
717-249-5322
Statement Date Due Date
03/31/2012 Upon Receipt
ACCOUNT NUMBER
802839
AMOUNT PAID $
RUTH C AUSIN
c/o MICHAEL BLESS
22 SUMMITT PLACE
CEDAR HILL, TX 75104
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 end return this portion with your remittance to the address; above
10lE15/19 -10/05/11 Adult Wpe Tubs (1) $4.07 y
$(4:07)
ID/131t1 - 10!1:3111
Puliups - tulediUm
(1)
$14:50
$(14
5Q) $13,060.24
10113111 - 10/13/31 Adult Wipes Refills
f1)
$2.88 .
88)
$(2 $-MW.74
10/19/11 - 10/19111 Adult Wipes Refills
f1)
$2
88 .
1 $1.3,042;86
10119111 - 10/'19 11 Wash 8 Set . $(2.
00)
. $13.03rg.98
10124111 - 10124111
Puflups -Medium- (1)
$13.00
$(13:00)
$13;028,88
1.0/26/11 - 10/26?11
Color rinse
set (1) $14:50 $(14;50)
$13,012.48.
0/28!11 - 10!28111 ,
Laundry f1) $14.20 $(14.20) $12;890;28
f1) $30.48 $(30:48) $12. ;987:.80
TOTAL BALANCE DUE:
- $1 Z,!#678U
.I
Ty NAME RESIDENT NAME
?H OF Goff 1-tnMF INf; Rt 1T41.! d;i iRriu ACCOUNT NUMBER
OAnnnn
r ~;
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
CHURCH OF GOD HOME, INC.,
Plaintiff,
v.
RUTH AUBIN and
MICHAEL BLESS, individually and as Agent
through a Power of Attorney for RUTH
AUBIN,
Defendants.
CIVIL ACTION -LAW ~ P.~
~~~
+~'~ I~,J
DOCKET NO.: 12-3858
v~
cn~`
-~?~ rv
a
r --
-~ c'
c-:,
~ ~LL~
,~, w
cv
PRAECIPE TO WITHDRAW. DISCONTINUE AND END
AND NOW, comes Church of God Home, Inc. ("Church of God"), by and
attorneys, SCHUTJER BOGAR, and files the within Praecipe to Withdraw, Discontinue and End
above-noted action, which consists of a Complaint against Defendants Ruth Aubin and
Bless. As the underlying issues have been resolved, there is no longer a necessity to maintain
aforementioned action and Church of God respectfully requests that the above captioned
be withdrawn without prejudice, without costs and without fees.
Dated: ~ ~ ~] ~-
Respectfully submitted,
SC TJER BOGAR
By:
Iv a Gru' ,Esquire
PA Atto y I.D. No.: 311922
Phone No: (856) 533-2464
Fax No.: (856) 533-2461
Kirk S. Sohonage, Esquire
PA Attorney I.D. No.: 77851
Phone No.: (717) 909-8160
Fax No.: (717) 909-5925
1426 North 3rd Street, Suite 200
Harrisburg, PA 17102
F
-~'. '7'€
~:
c=,
its
Attorneys for Plaintiff ~ ~ ~ ~ ~I A ~
CERTIFICATE OF SERVICE
I hereby certify that a true and correct copy of the foregoing Praecipe to
Discontinue and End was served via first-class, United States mail, postage prepaid, upon
following:
Ruth Aubin
c/o Country Meadows of West Shore
4837 East Trindle Road
Mechanicsburg, Pennsylvania 17050
Michael Bless
22 Summit Place
Cedar Hill, Texas 75104
Dated: ~ ~ ~ a By: V
J elle Valore, Paralegal