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Home My WebLink About04-6054 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. No. 04 - Io(jSl{ c.'lV~tT8<-~ PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION - LAW NOTICE YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE, IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTH CARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. No. PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION - LAW A VISO USTED HA SIDO DEMAND ADO / A EN CORTE. Si usted desea defenderse de las demand as 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 A viso radicando personalmente 0 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 Ie 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 rec1amada en la demanda 0 cualquier otra rec1amacion 0 remedio solicitado por el demand ante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero 0 propiedad u otros derechos importantes para usted. USTED DE BE LLEV AR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO 0 NO PUEDE PAGARLE A UNO, LLAME 0 VA Y A A LA SIGUIENTE OFICINA PARA A VERIGUAR DONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Cumberland County Bar Assoication 32 S. Bedford Street Carlisle, P A 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/ a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. No. Dlf - toOSt.{ C~~LY~~ PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION - LAW COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/ a ManorCare Health Services - Carlisle, ("Plaintiff ManorCare"), by and through its attorneys, KENNEDY BOGAR LLC, and files the within complaint against Defendant, Phyllis Carothers, and in support thereof, provides as follows: 1. Plaintiff ManorCare is a Delaware corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 940 Walnut Bottom Road, Carlisle, Pennsylvania 17013. 2. Defendant Phyllis Carothers is an adult individual who currently resides at 154 Lincoln Street, Carlisle, Pennsylvania 17013. 3. On or about October 8, 2003, Defendant Phyllis Carothers made application on behalf of her Mother, Christine Brady ("Mother" or "Christine Brady"), for admission to Plaintiff ManorCare's skilled nursing facility. 4. On or about October 8, 2003, Plaintiff ManorCare and Defendant Phyllis Carothers entered into a written Admission Agreement (" Agreement"), pursuant to which Plaintiff ManorCare agreed to provide Defendant Phyllis Carothers' Mother with skilled nursing care and services in exchange for, among other things, her promise to either pay a specific monetary fee from her Mother's assets, or make application for Medical Assistance benefits if her Mother could not afford to pay said fee. A true and correct copy of the Agreement is attached hereto as Exhibit" A". 5. Shortly after Christine Brady's admission to Plaintiff ManorCare's skilled nursing care facility, Ms. Brady allegedly became insolvent. As a result, pursuant to the Agreement, Plaintiff ManorCare notified Defendant Phyllis Carothers of her contractual duty to make application for Medical Assistance, and she subsequently filed an application for Medical Assistance benefits on her Mother's behalf. 6. The application for Medical Assistance benefits referenced above was approved on August 25, 2004 with an effective date of December I, 2003. A true and correct copy of Approval Letter is attached hereto as Exhibit "B". 7. Pursuant to Pennsylvania Department of Public Welfare Regulations, Christine Brady was directed to pay her "monthly income" as calculated by the Cumberland County Assistance Office to Plaintiff ManorCare commencing on her eligibility effective date - December I, 2003. 8, Upon information and belief, at all times material hereto Defendant Phyllis Carothers received her Mother's monthly income. 9. At all times material hereto, Plaintiff Little Flower Manor had an immediate right to possession of Christine Brady's monthly income, 2 COUNT I - CONVERSION Plaintiff ManorCare v. Defendant Phyllis Carothers 10. Paragraphs 1 through 9 above are incorporated herein by reference as if fully set forth at length. 11. At all times material hereto Defendant Phyllis Carothers converted, misappropriated and deprived Christine Brady of her right in, use and/ or possession of her monthly income. 12. At all times material hereto Defendant Phyllis Carothers' conversion, misappropriation and deprivation of Christine Brady's monthly income has been beyond her authority as her Mother's agent and for the purpose of hindering and/ or delaying the transfer of said monthly income to Plaintiff ManorCare. 13. At all times material hereto, Plaintiff ManorCare has had an immediate right to possession of Christine Brady's monthly income. 14. As a result of the foregoing unlawful actions of Defendant Phyllis Carothers, Plaintiff ManorCare has incurred damages in the amount of $16,226.60. WHEREFORE, Plaintiff ManorCare demands judgment in its favor and against Defendant Phyllis Carothers in the amount of $16,226.70 plus interest. COUNT II - VIOLATION OF UNIFORM FRAUDULENT TRANSFER ACT Plaintiff ManorCare v. Defendant Phyllis Carothers 15. Paragraphs 1 through 14 above are incorporated herein by reference as if fully set forth at length. 3 16. At all times material hereto, Defendant Phyllis Carothers, in her capacity as responsible person and agent for her Mother, transferred her Mother's monthly income to herself and/ or others without adequate consideration and for the purpose of hindering and/ or delaying its transfer to Plaintiff ManorCare. 17. Upon information and belief, at all times material hereto, Defendant Phyllis Carothers has accepted in her personal capacity the transfer of her Mother's monthly income with full knowledge that its purpose has been without intent to pay Plaintiff ManorCare for the skilled nursing care and services that it has rendered to Christine Brady in accordance with the terms and conditions of the Agreement. WHEREFORE, Plaintiff ManorCare demands judgment in its favor and against Defendant Phyllis Carothers in the amount of $16,226.60 plus interest. Respectfully submitted, KENNEDY BOGAR LLC Dated: ll/16 ( 6 \J\ ByQw~tg9' ~q Attorney I.D. No. 83755 Bradley A. Schutjer Attorney I.D. No. 75954 P,O, Box 959 Camp Hill, PA 17001-0959 717.909.5290 Attorneys for Plaintiff 4 RX,Date/Time NOV-29-2004(MON) 14: 51 717 249 0647 NOV 29 2004 15:41 FR MRNOR CRRE-CRRLISLE 717 249 0647 TO 9095925 I'IUV-Cll-CUUlllIIJCUJ 1:1: UII "'I:IIII~UY I OUYdr LLL lrP1;'1111 'U", :1,::1 P,006 P.06/06 1', UUOI UUO ~4nQ'N' The \U'\dersigned hereby veri5es that the statements of fact in the foregoing Complaint are true and correct to the best ofrny knowledg~, infotmation and belief. I understand that any false statements therein are subjeet to the pel'\alties contained in 18 Pa. C.S.A. 94904, relating to unsworn falsification to a~thorities. Dated: /;/;)9 )eLl U/JU) /Y)a A.A h Amy Marsl( Direc:t:or of Finance NOu 24 20a4 15:52 ?1? 9~9 5925 PAGE. 06 ** TOTRL PRGE.06 ** EXHIBIT "A" HCR Manor Care Pennsylvania ADMISSION AGREEMENT This Agreement is entered into by and among Manor Care Health Services, d.b.a. HCR Manor Care ("HCR Manor Care"), the Resident, and the Responsible Party, if any, for the 'purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Center ("Center"). Center: MCHS-Carlisle Resident: Christine R. Brady Responsible Party: Jennifer Reid Admission Date: 09/16/2003 Deposit: $ Q Term: This Agreement begins on the day the Resident enters the Center and ends on the day the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Resident's discharge date. I. RIGHTS AND RESPONSm~ITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident will pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section will not apply if the Resident is covered under a governmental program (see Section 1.05) or by a third party payor or managed care organization (see Section 1.06), 1.02 Ancillary Charges. The Resident will pay to Center all charges for additional' medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges will be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. 1.03 CollectionslLate Payments, Payment is due in full within thirty (30) days of billing. Should the Resident's account for any reason be turned over for collection, the Resident will pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. 'The Resident is directly responsible to" independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center will accept payments under such program in accordance with the terms of the program as set forth in the contract the Center has with the program. The Resident is responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmentalprogram(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in' the following programs: _x _ Medicare~ _x_Medicaid and! or _V A. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also p~icipates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident agrees to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. The Resident and/or Responsible Party are responsible for applying [Dr Medicaid. If the Resident receives Medicaid, most ,of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate.from their monthly income, The Resident agrees to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident fails to pay the. contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Payors and Managed Care Organizations, If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("Hl\10"), Preferred Pro:vider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident is responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time, 1.07 Private Pay Resident. The Resident is responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for any governmental program or covered under any third party payor or managed care organization plan. The Resident and/or Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Responsible Party will notify the Center in writing when application to Medicaid is made. The Resident and/or Responsible Party will cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in acco~dance with this Agreement, Resident Handbook and state and federal laws. . 1.08 Admission Information. The Resident and/or Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission. and throughout the Resident's stay including copies of insurance cards, identification or verification of eligibility and coverage information. ' The Resident and/or Responsible Party will provide the Center in writing with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the ,information supplied regarding such coverage. The Resident acknowledges that if the Resident fails to provide such information, the Resident may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center has no obligation to bill 'any third party payor other than the Responsible 'Party and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary Responsibility for Payment, Except for payments for services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Responsible Party acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This agreement serves as a written notice that the Center has notified the Resident and/or Responsible Party that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Responsible Party will be responsible for non-covered services. A . price list of services is maintained at the Center's business office and is available for review during regular business hours. 1.11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and abides by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Responsible Party must immediately notify the Center of the new physician's name., If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center will call another physician to attend to the Resident and the fees charged by such physician will be borne by the Resident. 1.12 Pharmacy. The Resident and/or Responsible Party has the right to choose a pharmacy of choice, provided the pharmacy sele'cted. is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. n, RIGHTS AND RESPONSIBILITY OF mE RESPONSIBLE PARTY 2.01 Legal Authority. The Responsible.Party represents that he/she has legal access to the Resident's mcome or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur personal financial liability on behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resources. 2.03 Requested Items. The Responsible Party will be personally liable for any services or products specifically requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. lithe Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Responsible Party must notify the Center in writing and must promptly apply for Medicaid benefits. If the Resident and/or Responsible Party fails to notify the Center in writing or fails to file for Medicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibility to Medicaid, the Center may end this agreement and transfer or discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06, In addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Responsible Party will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Cooperation for Financial Assistance. If the Resident is eligible for Medicaid, the Responsible Party must provide such information about the Resident's finances as Medicaid representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. lfthe Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid payments, and as a result Medicaid does not pay for the Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable notice for nonpayment, as provided in Section 4.06. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the Center. If after notice, the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, ifthe Resident's condition permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements and to pay promptly all charges. 2.07 Additional Responsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Resident Handbook, and Attachments. 2.08 Misuse of Resident Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding the Responsible Party's obligation to make payments on behalf ofthe Resid,ent under Section 2,02 or for purposes of qualifying the resident for Medicaid eligibility, the Responsible Party may be liable to the Medicaid agency and/or the Center for care that should have been paid for from the Resident's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or civil ~anctions against the Responsible Party. ill. RIGHTS AND RESPONSffiILITIES OF THE CENTER 3.01 Room and Standard 'Services. As part of the Room and Board Rate, the Center will furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit will be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by 'State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) days of the Center's receipt of the fmal Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Responsible Party hereby consents to the' release of the Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any person, firm, government entity, third party payor or managed care organization responsible for all or any part of the. payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any persoh authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Responsible Party consent ~o the use and disclosure of Resident's protected health information for the purposes of receiving treatment from the Center, obtaining payment for healthcare services provided to Resident, and the Center's own healthcare operation needs. The Resident and/or Responsible Party, by signing this Agreement, authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicabie, the undersigned Responsible Party represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services, Policies and Additional Information. The Resident and/or Responsible Party acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable, The Resident and/or Responsible Party acknowledge they have had the opportUnity to ask questions and questions have been answered satisfactorily. a. Assignment for Payment of Benefits. See Attachment C. b. sm Medicare Determination Notice. See Attachment D, c. Medicare Secondary Payor Questionnaire. See Attachment E. d. At the request of the Resident and/or Responsible Party, the Center will maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F-l and F-2. e. Center Supplement: 1. Policy and procedure on bedholds, election of bed holds and readmission. 2. Social Service Agencies and Advocacy Groups addresses and phone numbers. 3. N arne, address and phone number of Ombudsman. ' 4. Location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. S. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. 6. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. f. The Resident Handbook. g. ResidentlPatient Rights, h, MedicarelMedicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. 1. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachments G-1 and G-2. J. Privacy Act Notification. See Attachment H. k. Notice ofInformation Practices and Receipt of Notice ofInformation Practices. See Attachments I-I and 1-2. I. Ancillary Services Management Form. See Attachment J. 4.05 Assignment of Benefits: The Resident and/or Responsible Party request that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf for any s'ervice furnished by or in the Center. The Resident and/or Responsible Party authorize the Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third party payors any information needed to determine these benefits or benefits for related services, 4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Responsible Party may tenninate this Agreement by providing the Center written notice of the Resident's, desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time) the Resident must still pay for each day of the required notice unless the Center ,fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the admission ends. Discharge from the specialized units such as the Transitional' Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Responsible Party or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate) investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center)s employees and agents. 4.08 Changes in the Law. Any provision of this Agreement that is found to be invalid or unenforceable as a result of a change in state or federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH,READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED TO THElR SATISFACTION. Signature of Resident: Date: Signature of Responsible Party~ J1, L (b t,.., ~ Center Representative: U.6 (()J~ Date:~ /0-' rf'/03 Date: (6 -8 "'CJ3 EXHIBIT "B" PA/FS 162.8.95 NOTICE TO APPLICANT ,. BENEFIT ELIGIBLE El~a~LE PENDING 1-800-269.0173 717.240-2700 DEPARTMENT OF PUBLIC WELFARE CUMBERLAND COUNTY ASSISTANCE OFFICE 33 WESTMINSTER ORJVE p, O. BOX 599 CARLISLE, PA 17013.Q599 1I.'4.1IJ;:fl,I::{!1 =I~~~",'![If:.'" l.li!I:.J:'~1I:1 :::I:::IlUIiil~ll~lH:::I...J'~~I.:t'L'lij~ Gh\!..-\J:1~:i~'1:ir:l:1~t1~I:fu'll;M:l1n!I:tI: :::I~r:r;lnr;.ii:lgrClWJ~If:l:flte'iI~""'- I'l/I MEDICAL X ~ ASSISTANCE Alter the lirst check which may be a special emount you will receive $ o Twice a Month 0 Once a Month 0 In the Mail 0 At the Bank o You have a patient pay liability of $ l for the period beginning and ending Affective Date 1"2.. \ \ 03 You will receive $ lor the month(s) of then you will receive food stamps In the amount ot $ a month lrom to 0 In the Mall 0 At the Bank ""\ O ASSISTANCE CHECK O FOOD STAMPS ~ NURSING HOME CARE X o ~~W~~hs 0 g:;~) Level of care authorized /IJ P'S you are expected to pay $ f) e.tl... a month toward your care. ~ Ttf::: rC~.LO\II,'lr~~ P::.RS::':S .~~i~ INCL~Jr.;:~:l . I , ".1- ..~ I I \",0.1.. I . , I .)0..... ..... I _._'u.~_.,::_ ._ ._ _ ._i_,,~~~t_:Y:~_1 :.:'_.!i:;_;~:i..'.'_'~",:,~,_~!. . ; .:,:~st;t::_r:. __,,':'i:_! __ .__ _' _:: "_:. ._ _ rrL,~.::;;"~ .:_, :..3-.:2}; :- .~:;.;:-:~: '~;';:.~:.;=. -. .~~--_. --, .O.!..J__ C"f1....'1....~~~_-.Ja!Wc:...4L.L____ !__ ._~._.._ ___ _ _. ._. _ _ __ __ _ ..________: __ _ L__ ._~. ___.'_'___ SSNt: /62 . 3G '(139 ;;-'1" I REC 790 )4 ")..2 5?-2- , 55 PA CODE 1Iu=1I.:...~tli.I.]~II:V~~"tl:I~~~III'~':~~~I:I:("~'II.:'I=I'.lr-.:I::ll~.JIlf(.111'm[eII;t'll'U""~UI'J:l::(C'lIJIf~'tI.I'U" Regulation 125.84 I Reason Code 0 f J You are eligible for Nursing Home Care Medical Assistance effective ~(j,c.. II ,^003 R.eport all changes within 10 days to your ongoing caseworker who is J-lo I Il.l, / ~Aso'l1..Q SEE ATTACHED <J .. 1 ~Il\ll1.J~~'~IVAI_~["":l~~V1T~:l.:,~~r~~~.=-~III~lIl'~eI']~I:iII)::Q:~"['1~1I1~~'J~Il~:4~111'1~[~Il;J~~14IVI['1'J~"'l"~~'!:.:J:l~I=-V~__ , o FOOD' STAMPS ;, ,'; ;.. ,""" '. ':': ',' 'Number of Per~cimi ~l . 0 ASSISTANCE:CH5CK , ";' ;., :,', Number' of persons"'l $ $ $ GROSS MONiHL Y EARNEO INCOME _1 GROSS MONTHLY UNEARNED INCOME - $ $ $ GROSS MONTHLY EARNED INCOME 1/ /f / ' / 11, GROSS MONTHLY : "N~""I: Name Name S $ $ Name Name TOTAL GROSS MONTHLY INCOME GROSS MONTHLY DEPENDENT CARE COSTS GROSS MEDICAL COSTS $ $ $ '; TOTAL GROSS MONTHLY INCOME ': GROSS MONTHLY DEPENDENT CARE COSTS I: GROSS UTILITY COSTSIUTlLITY STANDARD" $ RENVMORTGAGE $ . TAXES $ INSURANCE COST ON HOME $ TOTAL SHELTER COST $ ":::::;:"':"'j';::' ':' ~':,'.;' ::'\::>r':):.'c,,^ ':\;":';;:'::-i"\ T:i', :,:/" :'.:';~:.' ;'-;",:,",c .';0:-:',;: ;,~':,o;~r;;\.i' \:" ::;;~,';'!\~~'>;'.' .,.::<,::".:, TOTAL GROSS MONTHLY INCOME "Tne .'10:;3(; ,:;.,d may ~a:';..~,' .:cfwc.o."l tile .,r:ll1u! u:.':tVcosts,'and..:the,"\,' stana",rd iJ:'ii:y, iJ,'::]V\',1'7CO :it IN] ti...'w ~'f ralp,"!iCi1~i(;jl.vi:'4rjd!:'oi1~'{F' NET MONTHLY INCOMElNET SEMI.ANNUAL INCOME t~a:1 il.,r~c!! t.rn~": au:.,'....7 D.a~~ two/v:). nlc.-,:."> P!HI~XJ. i'~~~~,~~~.~j.t~'~~i.~~~~::!-:~::~~~:::' ~ INCOME LIMIT If . ;.;DM.ED1CAt;;ASS1ST1diICE{;~ir{,;{:~i\: :l\!u(1i~e'!ol ~erscin~J!>:1 Name ~~~~~~~1,Hri~ : - GROSS MONTHLY , : UNEARNED I. ~ $ ~~; $ $ $ Telephone Electric Gas Oil Water/Sewage Garbage!frash Utility Installation Other Name $ $ $ I ~~ I RECORD NUMBER I CAT I CTRDIG I PAI0 q DIST I CY~r~~~1C <? J2SJ04 Date 2402744- Telephone Number 00 ~2~ i'o r C~~ rr 7/1.a./Yt.,s-t.ea.A.SL C~ '\ LEGAl HELP IS AVAIt.A61.E At.." LEGAL SERVICES, INC, B IRVINE ROW CARLISLE, PA 17013-3019 717-243-9400 717-766-8475 L .J 1~::g:~~il,:d,~~?fPr~~f~tihk~~[??'b;f1;ri:~?~~fk~~:q~~~i~q~~i;f?F?~qi:;qF~~~~?~:t'.l CLEN'f OO~V NAME ~~ '82~ q :2.~?O RECORD NUMBER INITIAL GROSS SS J 2103 MO/YR 4 ~-3:P :J.- 3' ~2 q6~~ I b~ q ~2 o 16 4q .'2 dot Mo/YR L\ b -3 " 0 231.Q2 qf:,'-l.OO ) b Sq ~2 o 'bSq ~2 MO/YR 'T\ ffi - G Qt:f opm' TOTAL GROSS UNEARNED ESTIMATED INTEREST TOTAL INCOME USED - PERSONAL CARE ALLO~JANCE .so ~o '-so ~{) - COMMUNITY SPOUSE/ HOME MAINTENANCE - MEDICAL EXPENSES (See below) o I' 'Cf~:Z 5'8'. "10 o '/c,?,q6? GROSS PATIENT PAY (53) LESS MEDICAL EXPENSES PAID MONTHLY NET PATIENT PAY (57) 1560. qZ MEDICAL EXPENSES LISTED \.2103 \I{).\ MO/YR MO/YR NOTE: Future changes in medial expenses should be reported to the Nursing Facility. DRUGS (54) ~"'?() 66~ MEDICARE (55) BC/BS/OTHER MEDI~AL INS (55) OTHER MEDICAL (56) 6f> ~'O bb~O MONTHLY TOTAL W (f)'V\'\J- ~doY\.. SIGNA-TURE ~ I.2S/o1 DATE REMINDER: The resource limit iS~$2400. See attached Addendum ~h $6000 disregard~ ;v~ t~ ~ ...() ....c:: -..J ~ ..t::::: -0 -GQ V) .'0 C/{ C> V fl: ~ .' , ~ i' ~l . j. ~.' . '.' (') r-) c::> ...;,~::> J-~- o ;-"() C; , f"') ~ -:";. o -n :1! ~ rn _!J I" -Cl~ rU "r' '::;; (') _'.' .. r (,L::;, _'J ;~; ~ri ,-) :T~ :n -< r"') .(.,- -..J IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v. No.: 04-6054 PHYLLIS CAROTHERS, Defendant, : CIVIL ACTION - EQUITY PRAECIPE FOR ENTRY OF AP.PEARANCE TO THE PROTHONOTARY: Kindly change the Court's records to reflect our new Firm information as follows: Schutjer Bogar LLC 441 Friendship Road, Suite 102 Harrisburg, PA 17111 Respectfully submitted, By: --"I W c /' ttorney Chadwick 0, Bogar Attorney I.D, 83755 441 Friendship Road, Suite 102 Harrisburg, PA 17111 (717) 909-5924 Fax (717) 909-5925 Dated: 1- /0- of Attorneys for Plaintiff CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe for Entry of Appearance was served via overnight delivery, upon the following: Phyllis Carothers 154 Lincoln Street Carlisle, PA 17013 Dated: (if ~O//)t)- , ~ / / :/' ^ --Li' ' .' J<:li Christy Ug, paralega!, By: (") rJ r:'--:' ( :~ \ ,:..J' (~ () -;'1 -','.'" . ,~- - \"-J -'~. r:? .-::' C~) - IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/ a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v, No,: 04-6054 PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION - EQUITY PRAECIPE FOR DEFAULT WDGMENT, ASSESSMENT OF DAMAGES AND VERIFICATION OF ADDRESS AND NON-MILrrARY SERVICE TO THE PROTHONOTARY: Enter judgment in favor of the plaintiff and against the above-named defendant for want of an answer, and assess the plaintiff's damages, exclusive of interest, as follows: Judgment in the amount of $16,226,60 plus interest, Understanding the false statements made herein are subject to penalty under 18 Pa. C.S.A. S 4904, Unsworn Falsification to Authorities, I verify that: 1. The precise last known address of the above-named defendant, Phyllis Carothers, is 154 Lincoln Street, Carlisle, Pennsylvania 17013, 2. The annexed notice of intention to file praecipe was mailed to the defendant and to her record attorney, if any, after default occurred, and at least ten days prior to the date of filing of this praecipe, 3. The said defendant is not in the military service of the United States or otherwise within the coverage of the Soldiers and Sailors Relief Act and is over 18 years of age. Respectfully submitted, SCHUTJER BOGAR LLC Dated: 2 - i()- 0 f By . Scott Foster Attorney 1.0. No. 90266 Chadwick 0, Bogar Attorney 1.0. No, 83755 441 Friendship Road, Suite 102 Harrisburg, PA 17111 Attorneys for Plaintiff This / /+~ day of ):-&~ ' .2005, Judgment is entered in favor of plaintiff and against defendant, Phyllis Carothers, by default for want of an answer and damages assessed at the sum of $16,226.60 plus interest, as per the above certification. Notice given pursuant to Pa, R.c.P. 236, Prothonotary IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEALTHCARE CORP, d/b/a MANORCARE HEALTH SERVICES- CARLISLE, Plaintiff, v. No,: 04-6054 PHYLLIS CAROTHERS, Defendant. : CIVIL ACTION - EQUITY RULE 236 NOTICE OF ENTRY OF ORDER, DECREE OR JUDGMENT AND NOW THIS / J -/.-~day of JA b 2005, pursuant to Pa, R.CP. 236 of the Supreme Court of Pennsylvania, you, defendant Phyllis Carothers, are hereby notified that Judgment by default in the amount of $16,226,60 exclusive of interest, has been entered in favor of the Plaintiff and against you, The following party is entitled to receive notice under Pa. R.CP, 236(a)(2), Phyllis Carothers 154 Lincoln Street Carlisle, PA 17013 IF YOU HAVE ANY QUESTIONS CONCERNING THIS NOTICE, PLEASE CALL ATTORNEY: W, SCOTT FOSTER, ESQUIRE at this telephone number: 717,909.5924, CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe for Default Judgment, Assessment of Damages and Verification of Address and Non-Military Service was served by first-class United States mail, postage prepaid, upon the following: Phyllis Carothers 154 Lincoln Street Carlisle, PA 17013 Dated: ()C)..f6)IJS- By: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP, d/b/a MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, v, No,: 04-6054 PHYLLIS CAROTHERS, Defendant, : CIVIL ACTION - EQUITY DATE OF NOTICE: January 10, 2005 IMPORTANT NOTICE TO: Phyllis Carothers 154 Lincoln Street Carlisle, P A 17013 Cumberland County YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORT ANT RIGHTS, YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP: Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 CERTIFICATE OF SERVICE I HEREBY CERTIFY that on this day I have served a true and correct copy of the foregoing Important Notice via United States, first-class mail, postage pre-paid, upon the following: Phyllis Carothers 154 Lincoln Street Carlisle,PA 17013 Cumberland County Date: o i /; O/(Y)- , SHERIFF'S RETURN - REGULAR CASE NO: 2004-06054 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND MANOR HEALTHCARE CORP DBA MANO VS CAROTHERS PHYLLIS GERALD WORTHINGTON , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE CAROTHERS PHYLLIS was served upon the DEFENDANT , at 1850:00 HOURS, on the 7th day of December, 2004 at 154 LINCOLN STREET CARLISLE, PA 17013 by handing to PHYLLIS CAROTHERS a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge 18.00 3.70 .00 10.00 .00 31.70 Sworn and Subscribed to before me this ol,/::- day of q / u::x; J~;:D.__ /(A~ O. '../.-0.-1 P othonotary , ~ So Answers: ;~r;}~~~~ R. Thomas Kline 12/08/2004 KENNEDY BOGAR BY~~ tJcxr:I~~ Deputy S~iff