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HomeMy WebLinkAbout13-3042 MAY /28/2013/TUE 01:43 PM HYNUM LAUD FAX No,717- 774 -0788 P,002 Supreme Q. 6 nnsylvaniia :i:abf_f_;:'_ii�iiir,�+ Cou f� leas For:. r..oihan.Dial ; sQn7y.;: >:i -:. County The information collected on this form is used solely for court administration purposes. This form does not supplement or replace the filing and service ofpleadings or other papers as required by law or rules of court. Commencement of Action: S 1 r �, Complaint El Writ of Summons 0 Petition Q Transfer from Another Jurisdiction Declaration of Taking I ead Plaintiff's Name: Lead Defendant's Name: o x � Diakon Lutheran Social Ministries Gayle Hollman Are money dama es r eq uested? Yes ix No Dollar Amount Requested: within arbitration limits Y g (check onle) ]outside arbitration limits '; Is this a Class Action Suit? rl. Yes No Is this an AM JAppeal? J Yes 0 No rl Name of Plaintiff/Appellant's Attorney: Brian K. Zelfner, Esquire Check here if you have no attorney are a Self-Represented (Pro Sel Litigant .. 1. ,n�wY,. r..an.r:u.,..cG :, ....�.. .. _..:- .- .... ... ...... ,...... ._.. .... .w...:....,.,., <,. :•..,..r- ;;p•n'��, - .. I ,Y,� , ..:T.:n v:.v', . ..a, .....: -...., .., ....... . �.. .. .. ..SJ _ • .li r.. ia, .,......., . � •: �, l� iii.Jrm . 6 : R D a ., N�ttYreMotufhe Case '.. ace;at�.:al to fheleffi;oftilev a2' bst:acctitatel a.es'c>ib'es`; "Doti ...'S4A .. in�: qq H�'i• ey : 9 i d..: 1�AR$9CA.4..Irfi uraas,makttl oxe^tk;ti�,ozza: } � eo � ° ']i1reorieltn.„rn,�n, no;s , �m ��nzr ...v..m „n .. n rmo�. n: :Yn:.[Bn�n�,A'I;.,,o•.�^+""''I ... ... .....,._..... .:..H,_m.v.: ��:.,< . � ..�Y•.. �l . ..�:.. - aq� «n��ran °rn�nwwurr. Hen�nmkar:. <,2 �r.. .... bgnr .cl, nn,•a.; wniMm '� .!�.r � '.�i <:;6'i- IlJn.r(: IMpI .M..... �. Irl� 'n,nrlilFnnhn .i.lr I, piA[InnHNtlW:gMl:i •;iR[i la f., rn�n' - a^4 .iii 4i r 55 ;�J �Il[�I:q�afr] Il.Mlilii °11 i:1 Y7 [Li „rnYl , n e ou onsi erY oxtaxt . .... r N It ° •ry : nm _ IInn nr ie. c +: •I :Ud4 �r ii •.r�. r � i 11 .ImM I nll:v r - - In'r „•.nm,nnrm .� I -.... i �.:..... ,...i: =•..n. •....'.. _ .u....ur i � .vl:l.n pp m�f�ra . ��. ����: rn.: r.. n„ �. r,,. �,., r. r.... rrlm. nnum•,.,•,..,:;.r..,...�.r:�r., ....• I,•,. n _.- . ........:........,..,.g..r,:..g �Y,,. - Id n -. g. °i Ed TORT (do not include Mass Tory CONTRACT (do not include Judgments) CIVIL APPEALS MI! Intentional ® Buyer Plaintiff Administrative Agencies Malicious Prosecution E3 Debt Collection: Credit Card Board of Assessment %'ltr Motor vehicle I@ Debt Collection: Other U Board of Elections Nuisance Nursing Facility [3 Dept- of Transportation Promises Liability +` U Statutory Appeal: Other Q Product Liability (does not include mass tort) Q Employment Dispute: Discrimination [3 Slauder2ibel /Demation fa � M , Oth I te Q Employment Dispute: Other E2 Zoning Board [3 Other: " MASS TORT Other: V �! El Asbestos '. >.: i r: .. {' 1 M Tobacco ® Tonic Tort -DES' !r, Toxic Tort -Implant REA PROPERTY MISCELLANEOUS ;1 bra` p T oxic Waste �rl Ejectment] Common Law /Statutory Arbitration s . ®i Other. rl Eminent it D i/Cd ti Declaratory Judgment i; 'msrti �t E3 Ground Rent [3 Mandamus :y am E] Landlord/Tenant Dispute n Non - Domestic Relations Mortgage Foreclosure: Residential Restraining Order I �TJe )i"ROFESSIONAL LIABLITY ©' Mortgage Foreclosure: Commercial ri Quo Warranto 0 Dental F7 Partition Replevin Legal E3 Quiet Title Q Other: E3 Medical Q Other: EJ Other Professional: Updated L20011 � Brian K. Zellner, Esquire 1 HE P' , o THd,H,D T '4 R, Hynum Law Supreme Court ID #59262'8; ��:�� 2608 North 3 Street ������ Harrisburg, PA 17110 r �- LAND COUNTY (717) 774 -1357 , - 1, '1S ?`L V�} f�' r 'n ` IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL NO. lU/ MINISTRIES d /b /a CUMBERLAND CROSSINGS, Plaintiff, V. GAYLE HOLLMAN, 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 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 South Bedford Street Carlisle, PA 17013 Phone: (717) 249 -3166 aM4 �1a3. a th- ,� aQ Ic* 3 USTED HA SIDO DEMANIDADO EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de is proximos viente (20) dias despues de la notification de esta Demanda y aviso radicando personalmente o por rnedio de un abogado una comparecencia escrita y radicando en la Corte por escritosus defenses de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tornar accion como se escribe anteriormente, el caso puede proceder sin usted y un fallo por qualquier suma de dinero reclamada en la demandaa o cualquier otra reclamacion o remedio solicitado por el demandanta puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad y otros direchos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIENTE OFICINA. ESTAOFICINA PUEDE PRO VEERLE INFORMACION A CERCA DE COMO CONSEGLJTR UNABOGADO. ST USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSSIBLE QUE ESTA OFICINA LE PUEDA PRO VEER INFORMACION SOBRE AGENCIES QUE OFREZCAN SERVTCIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUECUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Phone: (717) 249 -3166 Brian K. Zellner, Esquire Hynum Law Supreme Court ID #59262 2608 North 3` Street Harrisburg, PA 17110 (717) 774 -1357 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL NO. MINISTRIES d /b /a CUMBERLAND CROSSINGS, Plaintiff, V. GAYLE HOLLMAN, Defendant. : CIVIL ACTION - LAW. COMPLAINT 1. Plaintiff Cumberland Crossings is a Senior Living Community of Diakon Lutheran Social Ministries located at 1 Longsdorf Way, Carlisle, PA 17015. 2. Defendant Gayle Hollman is an adult individual who resides at 1 Longsdorf Way, Carlisle, PA 17015. 3. The Defendant Gayle Hollman applied for admission to the Plaintiff and was admitted on June 27, 2011. 4. The Defendant Gayle Hollman on or about June 27, 2011 signed a Nursing Facility Admission Agreement. A true and correct copy of said Admission Agreement is attached hereto as Exhibit "A." 5. The Defendant Gayle Hollman has been a resident at the Plaintiff's facility since June 27, 2011. 6. The Plaintiff is owed $7,594.64 for skilled nursing services. Attached hereto as Exhibit "B" is true and correct copy of the Account Statement. COUNT I -- BREACH OF CONTRACT CUMBERLAND CROSSINGS v. GAYLE HOLLMAN 7. Paragraphs 1 through 6 are incorporated herein by reference as though set forth at length. 8. On or about June 27, 2011, Plaintiff and Defendant Gayle Hollman entered into an admission agreement pursuant to which Plaintiff agreed to admit the Defendant Gayle Hollman into its facility in consideration for Defendant's agreement to pay Plaintiff for the skilled nursing care and other services. A true and correct copy of said Admission Agreement is attached hereto as Exhibit "A." 9. Plaintiff provided skilled nursing care and other services to the Defendant Gayle Hollman since June 27, 2011. A true and correct copy of the account statement evidencing charges for the services rendered is attached as Exhibit "B." 10. The Defendant is $7,594.64 in arrears on payments to Plaintiff. Despite repeated demands by Plaintiff for payment, Defendant has failed and refused and continues to fail and refuse to pay this amount. 11. The failure to remit to Plaintiff the amount owed is a material breach of the agreement between the parties. 12. The breach, as aforesaid, has caused Plaintiff injury in the amount of $7,594.64. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against Defendant in the amount of $7,594.64; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action and pursuant to the Agreement between the parties; c. Granting Plaintiff interest at the statutory rate from June 27, 2011; and, d. Granting such other relief as the Court deems equitable and just. COUNT II — BREACH OF IMPLIED CONTRACT CUMBERLAND CROSSINGS v. GAYLE HOLLMAN In the event it is determined that no written contract between Plaintiff and Defendant as alleged in Count I, the Plaintiff alleges as follows: 13. Paragraphs 1 through 12 are incorporated herein by reference as though set forth at length. 14. On or about June 27, 2011, the Defendant Gayle Hollman agreed to pay Plaintiff for skilled nursing care and other services. 15. On or about June 27, 2011, Plaintiff admitted the Defendant Gayle Hollman. 16. The facts, as set forth herein, establish an implied in law and implied in fact contract. 17. Due to the existence of the implied in law and implied in fact contracts, Plaintiff is entitled to compensation for services rendered to Defendant Gayle Hollman. 18. Plaintiff has demanded payment under the terms of the implied in fact and implied in law contracts by sending invoices, but Defendant Gayle Hollman has refused to make payment. 19. Plaintiff has been damaged by the refusal of Defendant to pay for the skilled nursing care and other services provided, in breach of the implied in law and implied in fact contract. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against Defendant in the amount of 7,594.64; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action; c. Granting Plaintiff interest at the statutory rate from June 27, 2011; and, d. Granting such other relief as the Court deems equitable and just. COUNT III — UNJUST ENRICHMENT - QUANTUM MERUIT CUMBERLAND CROSSINGS v. GAYLE HOLLMAN In the event it is determined that no written contract and no implied -in -fact contract existed between Plaintiff and Defendant as alleged in Counts I and II, the Plaintiff alleges as follows: 20. Plaintiff hereby incorporates paragraphs 1 through 19 of this Complaint as if set forth at length herein. 21. As more fully described herein, Plaintiff's expectation of payment from the Defendant Gayle Hollman was reasonable. 22. The Plaintiff has conferred a substantial benefit upon the Defendant Gayle Hollman. 23, The Defendant Gayle Hollman retained the benefit of the bargain with Plaintiff. 24. The Defendant Gayle Hollman has been unjustly enriched at the expense of the Plaintiff. 25. Due to Defendant's unjust enrichment, the Plaintiff is entitled to proper compensation. 26. Defendant's unjust enrichment at the Plaintiff's expense has damaged the Plaintiff. 27. The fair market value of said services at the time they were furnished is $7,594.64. 28. The Defendant has refused to pay Plaintiff the fair market value for the services rendered to her. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against Defendant Gayle Hollman in the amount of $7,594.64; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action; c. Granting Plaintiff interest at the statutory rate from June 27, 2011; and, d. Granting such other relief as the Court deems equitable and just. COUNT 1V — FRAUD CUMBERLAND CROSSINGS v. GAYLE HOLLMAN 29. Paragraphs 1 through 28 hereof are incorporated herein by reference as though set forth at length. 30. In order to further induce Plaintiff to skilled nursing care and other services to Defendant Gayle Hollman, the Defendant Gayle Hollman represented to Plaintiff that she would pay for services rendered to her. 31. Plaintiff believes, and therefore avers, that such representation was materially false, in that Defendant Gayle Hollman has not paid. 32. Such material misrepresentation was made by Defendant Gayle Hollman with actual knowledge of its falsity, or in reckless disregard of its truth or falsity, as to the actual intent of Defendant with respect to her intent to pay for services. 33. In justifiable reliance upon the material misrepresentation of Defendant Gayle Hollman, Plaintiff provided the skilled nursing care and other services to the Defendant Gayle Hollman. 34. As a result of the misrepresentations of Defendant Gayle Holtman and her failure to pay as originally agreed, Plaintiff has been damaged in the amount of $7,594.64. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against Defendant in the amount of $7,594.64; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action; c. Granting Plaintiff interest at the statutory rate from June 27, 2011; and, d. Granting such other relief as the Court deems equitable and just. Date: S Zee 13 C� Brian K. Zellner Attorney ID 59262 Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 [717] 774 -1357 Attorney for Plaintiff VERIFICATI s I i i I, �c r tr,�. �: _ hereby state that I am the authorized representative of the Plaintiff in this a pion and that the statements of fact made in the foregoing Complaint are true and correct to the best of my information and belief. The undersigned understands that the statements herein are made subject to the penalties of 18 Pa. Cons. Stat. Ann, 4904 relating to unsworn falsification to r authorities. i Printed Name i Title: V J A } a . i Y } } 1 l - I i r A MANY HANDS. ONE HEART. D IAKO N LUTHERAN SOCIAL M1D IMIES NURSING FACIIUTY ADMISSION AGREEMENT �f This Nursing Facility Admission Agre ent ("Agreement' is made on y of 1 aAjr , 201_L by and between ;$S 0/'1 ("Facility"), a facility of Diakon Lutheran Social Ministries and (referred to below as "You "). A. Facility is a licensed nursing facility located in �� , Pennsylvania. S. You are an individual in need of the nursing services that Facility provides and You agree to be admitted to Facility for the provision of nursing services within the capability of Facility. ❑ has been appointed by You through a durable Power of Attorney or Advance Directive to make admission and/or financial decisions on Your behalf (copy of document attached). OR , ❑ : has been appointed guardian by a court to make admission and/or financial decisions on Your behalf (copy of document attached). The above-named 'individual shall be referred to below. as "Your legal representative ". [If You have designated a "responsible "parry", Your responsible party may. execute this Agreement on Your behalf However, Your responsible party may not make health care and/or financial decisions for You unless Your responsible party, also has legal authority to make such decisions as an agent under a-properly executed power of allomey or as Your court appointed guardian.] NOW THERE FORE, in consideration of the terms and covenants contained in this Agreement, the parties agree as follows: 1. Services Provided. a. Facility shall provide You with the appropriate level of nursing services and other specified items and services within the capacity and capability of the Facility. These services shall be provided as part of the daily room rate ("Daily Rate") and include basic room, meals, general nursing care, activity program, housekeeping services, bedding and Iinens, personal hygiene supplies, and routine nursing supplies. Facility may also provide additional services ( "Additional Services ") upon Your request or as otherwise required by Your condition, within the capacity of Facility. You hereby acknowledge that You have been advised verbally of the Daily Rate and charges for Additional Services and that a written schedule of the Daily Rate and Additional Services has been provided to You and/or Your legal representative. b. Facility reserves the right to change the Daily Rate and the charges for Additional Services at any time. Facility shall notify You and/or Your legal representative in writ E IBIT PA SNF admission agreement -Rev. 1.07 b i f c. not less than thirty (30) days prior to any change in the Daily Rate and/or the charges for Additional Services. d. Physician services: You or Your legal representative shall designate a physician, who . must be properly licensed and must abide by applicable laws, regulations, and the policies of Facility, to be responsible for the medical evaluation of You and to prescribe a planned regimen of care. Your physician must be credentialed by Facility prior to providing services to You at Facility. You understand that in the event Your attending 'physician is not available or in an emergency, Facility may engage any licensed physician to attend to You and to render medical treatment. 2. Consent. By entering into this Agreement, You and/or Your legal representative consent to the assessment treatment, and care of You by Facility within the means, capacity and capability of Facility. 3. Payment for Services. a... Daily Rate You and/or Your legal representative shall be responsible to pay the Daily Rate of the Facility. if You are eligible for coverage under a governmental program or by a third party payor or managed care organization, Your Daily Rate may be fully or partially covered. However, You and/or Your legal representative shall be responsible for any deductibles, required co- insurance, patient liability payments, or non - covered charges. b. Additional Services You and/or Your legal representative shall also be responsible for payment of Additional Services provided to You. if You are eligible for coverage under a governmental program or by a third: party payor or managed care organization, Additional Services may be My or partially covered. However, You and/or Your legal representative shall be responsible for any deductibles, required co- insurance, patient liability payments, or non - covered charges. c. Payment Dates Each month, You will receive a statement which includes two types of charges: the monthly fee due for the current month's room and board (at the Daily Rate) and any charges for Additional Services from the previous month. The statement will also reflect all payments deposited in the bank by the last day of the previous month. All bills by Facility to You are due and payable upon receipt. Payments may be made at Facility or mailed to FaciIity's lockbox in Philadelphia using the return envelope accompanying Your monthly statement. d. Collections/Late Pa means. You and/or Your legal representative shall be responsible to pay all actual attorney's fees and costs incurred by Facility relative to the collection of any amounts ninety. (90) days past due. e. Change in Chames. Facility reserves the right to increase or decrease the Daily Rate and charges for Additional Services provided to You. Facility shall provide You and/or Your legal representative with not less than thirty (3 0) days' notice prior to the expected increase or decrease. PA SNF admission agn—mment - Rev. 1.07 f. Failure to pay for services or apply for medical assistance 1n the event You and /or Your legal representative do not pay for services provided by Facility or in the event You and/or Your legal representative do not apply for medical assistance when Your resources are exhausted pursuant to Paragraph 7, You shall be discharged for nonpayment of stay. 4. Legal representative's authority. An individual executing this Agreement as a legal representative is representing that he /she has legal access to the resident's income and/or financial resources and that he /she will pay from the resident's income and/or financial resources all fees and charges for which the resident is liable under this Agreement. The legal representative assumes no financial responsibility beyond the resources of the resident. However, in the event that such legal representative misappropriates the resident's income and/or resources or otherwise illegally transfers assets, the legal representative may be Iiable to the Pennsylvania Department of Public 'Welfare and/or the Facility for the cost of care that should have been paid for by the resident. In addition, misappropriation of funds may also result in the imposition of civil or criminal penalties against the legal representative. 5. Admission Information, a. Responsibility to V ovide accurate and timely information Upon admission, and throughout Your stay, You and/or Your legal representative will notify Facility and provide all information needed regarding Your eligibility 'for coverage by third parry payors, managed care organizations, or governmental programs, including copies of insurance cards, coverage information, verification of eligibility, etc. b. Change in eligibility You and/or Your. legal representative must notify Facility in writing within five (5) days of a change in your coverage status, such as Your disenrolhment;- enrollment, failure to pay premiums or cancellation of coverage. If You and/or Your legal representative fail to provide such information, You and/or Your legal representative maybe responsible for any charges or costs incurred by Facility as a result. 6. Medicare. a. Facility is a participating provider in the Medicare program. Medicare may pay for limited skilled nursing days. Upon admission to Facility or during Your stay at Facility, if Facility expects that Medicare will not pay for the services provided to You under this Agreement, Facility shall inform You and/or Your legal representative in writing why the services may not be covered. b. Facility shall concurrently inform You and/or Your legal representative of Your right to demand that Your bill be submitted to Medicare. 7. Medical Assistance. a. .Facility is a participating provider in the Pennsylvania Medical Assistance Program. You and/or Your legal representative shall be responsible to apply for Medicaid on a timely basis if You are eligible. You and /or Your legal representative are responsible for giving Facility notice at least six (6) months in advance of the date Your resources will be PA SNF admission agreement - Rev. 1.07 exhausted. If You and/or Your legal representative do not apply for Medicaid on a timely . basis or do not provide information required by the Pennsylvania Department of Public Welfare to determine Your eligibility for Medicaid, Facility may transfer or discharge You for nonpayment of stay. b. You and/or Your legal representative are responsible for payment of any amounts that the Pennsylvania Department of Public Welfare or one of its local offices determines is Your contribution, or patient liability. If You and/or Your legal representative do not pay such amounts due, Facility muy transfer or discharge You for nonpayment of stay. c. Facility may charge for items and services not paid by Medicaid if charges are disclosed and agreed to by the parties in advance. d. Consistent with the reimbursement regulations of the Commonwealth of Pennsylvania, residents who are or who become beneficiaries of Medicaid will be accommodated in semi- private rooms. 8. Transfers and Discharges. a. Reasons for Transfer or Discharge Facility has the right to transfer or discharge You for Medical reasons, for Your welfare or that of other residents, or for nonpayment 'of stay if Facility has made reasonable efforts to. collect Your outstanding amounts due. b. Notice of Transfer or Discharge Except in emergency cases, Facility shall provide You ..and Your legal representative with not less than thirty (30) days' written notice prior to Your transfer or discharge, unless appropriate plans acceptable to You and/or Your legal representative are implemented sooner. c. Dischar ee Plan Facility shall provide a coordinated interdisciplinary discharge plan for You to ensure that You have a program of continuing care after discharge from Facility in accordance with Your needs. d. Transfers between Facilities If Facility terminates this Agreement or otherwise discharges or transfers You to another health care facility, Facility shall assure that appropriate arrangements are made for Your safe and orderly transfer and that You are transferred to an appropriate place capable of meeting Your needs. Facility shall provide clinical records describing Your needs, including a list of orders and medications directed by the attending physician', to the facility to which You are transferred. You may be charged for the costs of copying Your clinical records. e. Bed Hold Policy Prior to Your transfer for hospitalization or•therapeutic leave, Facility shall provide You with written notice of Your right to resume residence at Facility and Facility's bed hold policy in accordance with state law. f. Appeal and Fair Hearing for Medicare and Medicaid Beneficiaries You and/or Your legal representative shall have the right to an appeal and a fair hearing with respect to Facility's decision to transfer or discharge You. PA SNF admission agreement - Rev. 1 A7 ' y S 9, Termination by Facility. a. Failure to Pay Facility may discharge You and terminate this Agreement upon Your failure to pay for the services provided by Facility pursuant to the terns and conditions of this Agreement, including for Your failure to apply for Medicaid when eligible. Facility . shall provide You and/or Your legal representative with not less than thirty (30) days' notice of termination of this Agreement and Your discharge or transfer. b. Closure or Destruction of Facility Facility reserves the right to terminate this Agreement upon closure or destruction of Facility. In the event that Facility intends to close, Facility shall provide You and Your legal representative with thirty (30) days' written notice of intent to close. You and/or Your legal representative shall be responsible to pay all fees incurred prior to the date of termination. 10. Termination by You (Applicable only to private pay residents.) You and/or Your legal representative may terminate this Agreement for any reason upon seven (7) days' written notice to Facility. Except in the case of an emergency transfer or death, if You and/or Your legal representative do not give the required seven (7) days'. written notice, You and/or Your legal representative will be responsible for payment of the Daily Rate for each day of the required notice, regardless of whether You still resided at Facility. 11. Effect of Termination Upon, termination of this Agreement neither, party shall have any further obligations except obligations incurred.prior to the date of termination and as otherwise set forth in this Agreement 12. Refunds In the event of Your death, Facility shall - refund the following amount to Your personal representative or guardian within sixty (50) days of the date Your room is cleared of Your personal property: a. the amount of the difference between any payment made by You for monthly charges for "Oder care services" (as defined below) and,the cost of the "elder care services" actually _ provided to You. i. elder care services are services or treatment provided to meet a resident's need for personal care or health care, including, but not limited to, assistance with activities of daily living, physical, occupational or speech therapy, and medical social services. Room and board is not included in elder care services. 13. Inventory and storage of Your personal property after death. Facility shall contact Your representative or guardian within twenty -four (24) hours of Your death to ar ange for an inventory of Your personal property. a.' If Your representative or guardian is unable to claim Your personal property within three (3) business days after Your death, Facility may. place Your personal property in storage for up to thirty (30) days. PA SNP admission agreement - Rev. 1.07 b. If Your property is unclaimed after the storage period of thirty (30) days, Facility shall send notice by certified mail stating that Your personal property will be disposed of at the end of an additional fourteen (14) day period. c. If Your personal property is unclaimed following the additional fourteen (14) day period, Facility shall dispose of the property. 14. Advance Directives Facility has provided information to You about the Facility's policies .concerning implementation of Advance Directives, and a written description of Pennsylvania law concerning Advance Directives. Facility shall comply with Your rights under state law to make decisions concerning medical care, including the to accept or refuse medical or surgical treatment and the right to formulate advance directives and shall document in Your clinical record whether or not You have executed an advance directive. Facility does not condition the provision of medical care to You based on whether or not You have executed an advance directive. 15. Resident Funds a. Written Authorization Facility shall notrequire You to deposit personal funds with Facility. If You elect to deposit personal funds, upon Your and/or Your legal representative's written authorization, Facility shall hold, manage, safeguard and account for such personal funds at no additional charge to You. b. Deposit If You are a Medicare or Medicaid beneficiary, Facility shall deposit any amount:ofYour personal funds in excess of Dollars ($50) into an account that is separate from any of Facility's operating accounts and shall credit all interest earned on such separate account to such account. For amounts less than the amounts set forth above, Facility shall maintain such personal funds in a non - interest bearing account or petty cash fund. c. Accounting and Records Facility shall provide a complete and separate accounting of each Facility resident's personal funds, maintain a written record of all financial transactions involving Your personal funds deposited at Facility and afford You and/or Your legal representative reasonable access to such record. d. Disbursement iJpon Deaa`h In the event of Your death, Facility shall convey Your personal funds and accounting of such fiords to the individual administering Your estate, within thirty (30) days of Your death. 16. Your Rights Facility has provided You and/or Your legal representative with a copy of Facility's Resident Rights outlining Your legal rights during Your stay at Facility, and You and /or Your legal representative acknowledge receiving information about Resident Rights. 17. Your Personal Property You shall be permitted to keep and use personal clothing and possessions as space in Facility permits unless to do so would infringe upon the rights of other residents and unless medically contraindicated, as reasonably determined by Facility. Facility shall make reasonable provisions for the handling and storage of Your personal PA SNF admission agreement- Rev. 1.07 clothing and possessions and provide You access to such clothing and possessions. You are advised not to have valuables such as large amounts of money, jewelry, etc. in the Facility. Facility will investigate all allegations of lost or misappropriated resident. property at Facility, but will be responsible for such lost or misappropriated property only in limited circumstances. 18. Visitors You shall be permitted to have visitors at Facility in accordance with all applicable policies and procedures of Facility. Facility reserves - the right to limit visitors or access to You -if Facility has determined that such access may be detrimental to Your care and well- being or in the event visitors are disruptive to other residents or the operations of Facility. Notwithstanding the foregoing, Facility shall not restrict access to Your legal counsel or representatives ofPennsylvania's Department of Aging. 19. Index inification You will defend, indemnify and hold Facility harmless from any and all claims, liabilities, damages, costs or expenses (including reasonable attorneys' fees) arising from or resulting in any manner from any of Your acts or omissions which damage or injure any person or the property of any person or of Facility. This provision. does not release the Facility from any Iiabilities or duties otherwise imposed by law. 20. IVIiseellaneous. a. Compliance with Laws Facility shall comply with all appficablefederal and statelaws, as may -be in effect from time to time. b. Governing Law This Agreement shall be governed by and construed in accordance with . the laws of the Commonwealth of Pennsylvania, notwithstanding any conflict of laws provisions to the contrary. c. Severability If any term or provision of this Agreement or the application thereof to any person or circumstance shall to any extent be invalid or unenforceable, the remainder of this Agreement or. the application of such term or provision to persons or circumstances other than those to which it is held invalid or unenforceable shall not be affected, and each term and provision of the Agreement shaft be valid and enforceable to the fullest extent permitted by' law. d. Assignment You may not assign this Agreement. e. Waiver The waiver by Facility of a breach of any provision of this Agreement by You shall not operate or be construed as a waiver of any subsequent breach by You. f. Notices Any notice required or permitted to be given under this Agreement shall be deemed properly given if in writing and if mailed by regular mail in the case of Your legal representative, delivered to Your room in the case of notices to You, or to the principal office of Facility in the case of notice to Facility. The effective date of any such notice shall be the date of mailing or the date of personal delivery, whichever is applicable. The address to which notice shall be sent may be changed by a written notice given pursuant to this Paragraph. PA SNF admission ageement - Rev. 1.07 s g. Non - Discrimination Facility shall not discriminate against You on the basis of Your sex, age, race, color, creed, national origin, sexual orientation, handicap or any other class protected by law. h. Entire Agreement ement This Agreement contains the entire Agreement of the parties relating . to the subject matter hereof. This Agreement supersedes and replaces in its entirety any existing agreement between You, Your legal representative and Facility regarding Your admission to Facility, and may not be waived, changed, modified, extended or discharged except by a writing executed by the Facility and by the party against whom enforcement of any such waiver, change, modification, extension or discharge is sought. i. Change in Law Facility reserves the right to amend this Agreement upon thirty (30) days' written notice to You and /or Your legal representative if any change in federal, state and local laws, regulations, policy and/or interpretation of the same, shall impair the continuing validity. and/or effectiveness of any material provisions of this Agreement. j. Headings The headings of the Paragraphs hereof are for convenience only and shall not control or affect the meaning or construction or limit the scope or intent of any of the provisions of this Agreement. k. Acknowledgment of Receipt of Resident Handbook and Notice of Practices You acknowledge receipt of Facility's Resident Handbook and H1PAA Notice of Privacy Practices. BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU RAVE READ'THE FOREGOING AGREEMENT AND THAT YOU HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THE AGREEMENT. IN WIT NESS WHEREOF, the parties have executed this Agreement as of the date first above written. FACILITY RESIDENT OR RESIDENT'S LEGAL REPRESENTATIVE OR RESIDENT'S RESPONSIBLE PA�RlT�Y, Name(printed Namie(prmted) PA SNF admission agreement - Rev. 1.07 STATEMENT Page: 1 01 1 Est? =::'- - '.'ar�`A• - D ® N .. .�iaf•• ... =o-:. _. ::_n✓. - >::� ..... " -. . ..x_:. __ rte., LUTHTIRAN SOCIAL MINJSTK(xS 130410 621CCNC 03/31/2013 Cumberland Crossings Retirement Community 1 Longsdorf Way _ ;t: '�yN:.p. g'�- Kf-1'� e_s °•<_::ki'a ><ec :!:= v`-'.;`c�. =':- „'t, <vs::_ : PA 17015 -7623 •:�:: ,.� - -_:;, . � : �ie.�: <` - ::3�'Arioun #::Pal -9 > -. Facility # (717) 245 -99'41 _ Carlisle _ >, :�:.,:_ :f .<.. _ - _., r:: !3° !:v> :,: d- '• . Business Office # (717) 240 -6040 4/23/2013 $7,594.64 . 4. '_'�:):�ti{`�.�Eir "'Cj':::��ti _r...( � -_ _- .�- . -.. �r`'';'_2;: ?: "Ti:•:!:, ^ Raphael Balthazar r 141.Tower Circle Hollman, Gayle R Carlisle, PA 17013 Please make check payable to Diakon Lutheran Social Ministries Gayle R Hollman Cumberland Crossings Retirement Community 03131/2013 Raphael Balthazar t- U -a. ss r:.� : - e c :Net -N ; e —, fWbd lfN . F l w ; ; r £� } y c� ti F k :� S 'Froin _2...,� : _ .ar..x. vr_.: .._- �I.:. <' ... ... ^.,...:r, ; _. 151�a `S�r ~C1dit$ :��� - -RESVENTRESPONSIBILITY 2/28/2013 Balance Forward $7,626.00 02101/2013 2/14/2013 Resident Liability (Feb) .00 -96.3 02/01/2013 3115/2013 Maintenance Service Charge 1.00 Unit 65.0 TOTAL BALANCE DUE $7,594.64 EXHIBIT a 8 Brian K.Zellner,Esquire Hynum Law Supreme Court ID#59262 2608 North 3rd Street Harrisburg,PA 17110 (717)774-1357 CD IN THE COURT OF COMMON PLEAS n CUMBERLAND COUNTY, PENNSYLVANIA j-nco DIAKON LUTHERAN SOCIAL NO. 13-3042 MINISTRIES d/b/a -<> CUMBERLAND CROSSINGS, � ,- Plaintiff, c E5 c CD V. co GAYLE HOLLMAN, Defendant, CIVIL ACTION - LAW PLAINTIFF'S MOTION TO AMEND COMPLAINT AND NOW, comes the Plaintiff, by and through its attorneys, Brian K. Zellner, Esquire and Hynum Law Office, and avers the following: 1. The Plaintiff, and/or its agents (hereinafter, collectively"Plaintiff") initiated this action by Complaint on or about May 28, 2013. 2. Subsequent to filing the Complaint, Plaintiff discovered Defendant, Gayle Hollman, passed away on March 21, 2013. 3. No Estate has been opened. 4. On June 27th, 2011, Enrico Hollman signed the Nursing Facility Admission Agreement as legal representative or responsible party for Gayle Hollman. 5. It is alleged and therefore averred Enrico Hollman abused his power and converted Gayle Hollman's funds for his own use. 6. Plaintiff wishes to amend its Complaint to remove Gayle Hollman as Defendant and add Enrico Hollman as Defendant. See attached hereto as Exhibit"A"proposed Amended Complaint. 7. The Statute of Limitations has not expired on any of the Plaintiff s claims. 8. Plaintiff files this motion pursuant to Pa. R.C.P. 1033 WHEREFORE, the Plaintiff respectfully requests that this Court grant Plaintiff's Motion to Amend the Complaint to remove Gayle Hollman as Defendant and add Enrico Hollman as Defendant. Date: G s / l� Brian K. Zellner, Esquire Attorney ID No. 59262 2608 North 3`d Street Harrisburg, PA 17110 (717) 774-1357 bzellner@.hynumpc.com Attorneys for Plaintiff Brian K. Zellner, Esquire Hynum Law Supreme Court ID#59262 2608 North 3`d Street Harrisburg, PA 17110 (717) 774-1357 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL NO. 13-3042 MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff, V. ENRICO HOLLMAN, 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 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 South Bedford Street Carlisle, PA 17013 Phone: (717) 249-3166 E E IBIT s USTED HA SIDO DEMANIDADO EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de is proximos viente (20) dias despues de la notification de esta Demanda y aviso radicando personalmente o por rnedio de un abogado una comparecencia escrita y radicando en la Corte por escritosus defenses de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tornar accion como se escribe anteriormente, el caso puede proceder sin usted y un fallo por qualquier suma de dinero reclamada en la demandaa o cualquier otra reclamacion o remedio solicitado por el demandanta puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad y otros direchos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIENTE OFICINA. ESTAOFICINA PUEDE PRO VEERLE INFORMACION A CERCA DE COMO CONSEGLJTR UNABOGADO. ST USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSSIBLE QUE ESTA OFICINA LE PUEDA PRO VEER INFORMACION SOBRE AGENCIES QUE OFREZCAN SERVTCIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUECUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Phone: (717) 249-3166 Brian K. Zellner, Esquire Hynum Law Supreme Court ID#59262 2608 North 3rd Street Harrisburg, PA 17110 (717)774-1357 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL NO. 13-3042 MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff, V. ENRICO HOLLMAN, : Defendant, : CIVIL ACTION - LAW AMENDED COMPLAINT 1. Plaintiff Cumberland Crossings is a Senior Living Community of Diakon Lutheran Social Ministries located at 1 Longsdorf Way, Carlisle, PA 17015. 2. Defendant Enrico Hollman is an adult individual who resides at 2674 N. Sherman Street, York, PA 17406-2332. 3. The Defendant's mother, Gayle Hollman, applied for admission to the Plaintiff and was admitted on June 27, 2011. 4. The Defendant on or about June 27, 2011 signed a Nursing Facility Admission Agreement. A true and correct copy of said Admission Agreement is attached hereto as Exhibit "A." 5. The Defendant's mother, Gayle Hollman, was a resident at the Plaintiff's facility from June 27, 2011 until her death on March 21, 2013. 6. The Plaintiff is owed $7,594.64 for skilled nursing services. Attached hereto as Exhibit "B" is true and correct copy of the Account Statement. COUNT I - BREACH OF CONTRACT CUMBERLAND CROSSINGS v. ENRICO HOLLMAN 7. Paragraphs 1 through 6 are incorporated herein by reference as though set forth at length. 8. On or about June 27, 2011, Plaintiff and Defendant entered into an admission, agreement pursuant to which Plaintiff agreed to admit the Defendant's mother, Gayle Hollman, into its facility in consideration for Defendant's agreement to pay Plaintiff for the skilled nursing care and other services. A true and correct copy of said Admission Agreement is attached hereto as Exhibit "A." 9. Plaintiff provided skilled nursing care and other services to the Defendant's mother, Gayle Holtman from June 27, 2011 until her death. A true and correct copy of the account statement evidencing charges for the services rendered is attached as Exhibit "B." 10. The Defendant as Power of Attorney for Gayle Hollman had access to her finances. 11. The Defendant is $7,594.64 in arrears on payments to Plaintiff. Despite repeated demands by Plaintiff for payment, Defendant has failed and refused and continues to fail and refuse to pay this amount. 12. It is believed and therefore averred that the Defendant converted Gayle Hollman's funds to his use. 13. The failure to remit to Plaintiff the amount owed is a material breach of the agreement between the parties. 14. The breach, as aforesaid, has caused Plaintiff injury in the amount of$7,594.64. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against Defendant in the amount of$7,594.64; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action and pursuant to the Agreement between the parties; c. Granting Plaintiff interest at the statutory rate from June 27, 2011; and, d. Granting such other relief as the Court deems equitable and just. COUNT II — BREACH OF IMPLIED CONTRACT CUMBERLAND CROSSINGS v. ENRICO HOLLMAN In the event it is determined that no written contract between Plaintiff and Defendant as alleged in Count I, the Plaintiff alleges as follows: 15. Paragraphs 1 through 14 are incorporated herein by reference as though set forth at length. 16. On or about June 27, 2011, the Defendant agreed to pay Plaintiff for skilled nursing care and other services. 17. On or about June 27, 2011, Plaintiff admitted the Defendant's mother, Gayle Hollman. 18. The facts, as set forth herein, establish an implied in law and implied in fact contract. 19. Due to the existence of the implied in law and implied in fact contracts, Plaintiff is entitled to compensation for services rendered to the Defendant's mother, Gayle Hollman. 20. Plaintiff has demanded payment under the terms of the implied in fact and implied in law contracts by sending invoices, but Defendant has refused to make payment. 21. Plaintiff has been damaged by the refusal of Defendant to pay for the skilled nursing care and other services provided, in breach of the implied in law and implied in fact contract. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against Defendant in the amount of 7,594.64; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action; c. Granting Plaintiff interest at the statutory rate from June 27, 2011; and, d. Granting such other relief as the Court deems equitable and just. Date: Brian K. Zellner Attorney ID 59262 Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 [717] 774-1357 VERIFICATION I, hereby state that I am the authorized representative of the Plaintiff in this action and that the statements of fact made in the foregoing Complaint are true and correct to the best of my information and belief. The undersigned understands that the statements herein are made subject to the penalties of 18 Pa. Cons. Stat. Ann. § 4904 relating to unsworn falsification to authorities. Date: Printed Name: Title: i"ILED-0Fj.CL,►: Of-' THE PROTIAONOTIAR'� Brian K.Zellner,Esquire Hynum Law 7913 SUN _6 A 10; 5 7 Supreme Court ID#59262 2608 North 3'Street CUMBERLAND COUNTY Harrisburg,PA 1711.0 PENNSYLVANIA (717)774-1357 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL NO. 13-3042 MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff, V. GAYLE HOLLMAN, Defendant, CIVIL ACTION- LAW SUGGESTION OF DEATH TO THE PROTHONOTARY: Defendant Gayle Hollman died on March 21, 2013. Dated: HYNUM LAW Brian K. Zellner, Esquire Supreme Court ID# 59262 2608 North 3rd Street Harrisburg, PA 1710 (717) 774-1357 Email: bzellnern hynum c com Attorneys for Plaintiff SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny RAnderson _ F1"LE 0°0 F1(:,=- r- Sheriff o i F�� >��0 -uoi: �, a �- t,, ,f ;�•;,t f Jody S Smith ° _ I .f Chief Deputy Richard W Stewart CJP�9r; LFau11 '° Solicitor rr; r t 1 l sa'Y U8\a,fl A Diakon Lutheran Social Ministries d/b/a Cumberland Crossings Case Number vs. Gayle Hollman 2013-3042 SHERIFF'S RETURN OF SERVICE 05/31/2013 03:24 PM- Ronny R Anderson, Sheriff, being duly sworn according to law, states he made diligent search and inquiry for the within named Defendant to wit: Gayle Hollman, but was unable to locate the Defendant in his bailiwick. The Sheriff therefore returns the within requested Complaint& Notice as"Not Found"at 1 Longsdorf Way, South Middleton, Carlisle, PA 17015. Deputies were advised by the Nursing Home Administrator that the defendant passed away approximately six weeks prior to our attempting service. SHERIFF COST: $39.78 SO ANSWERS, June 03, 2013 RbNW R ANDERSON, SHERIFF (c)CountySuite Sheritf,Teleosoft.Inc. DIAKON LUTHERAN IN THE COURT OF COMMON PLEAS OF SOCIAL MINISTRIES d/b/a CUMBERLAND COUNTY, PENNSYLVANIA CUMBERLAND CROSSINGS, Plaintiff V. CIVIL ACTION—LAW GAYLE HOLLMAN, Defendant NO. 13-3042 CIVIL TERM IN RE: PLAINTIFF'S MOTION TO AMEND COMPLAINT ORDER OF COURT AND NOW, this I I'h day of June, 2013, upon consideration of Plaintiffs Motion to Amend Complaint, a Rule is hereby issued upon the Estate of Gayle Hollman and Enrico Hollman to show cause why the relief requested should not be granted. RULE RETURNABLE within 20 days of service. BY THE COURT, Christ lee L. Peck, J. ✓Brian K. Zellner, Esq. -Hynum Law Office 2608 North 3rd Street Harrisburg, PA 17110 Attorney for Plaintiff nrico Hollman 2674 N. Sherman Street r ism York, PA 17406-2332 ) Defendant, pro Se >c ' w =" :rc Co m-�.LL (.ft a-/12 Brian K. Zellner, Esquire Hynum Law Supreme Court ID#59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL : NO. 13-3042 MINISTRIES d/b/a : CUMBERLAND CROSSINGS, • -d.r7? cam. • Plaintiff, cn �' V. • p t� • GAYLE HOLLMAN, • Defendant, : CIVIL ACTION - LAW PLAINTIFF'S MOTION TO MAKE RULE ABSOLUTE AND NOW comes Plaintiff, Diakon Lutheran Social Ministries d/b/a Cumberland Crossings, by and through its Counsel, Brian K. Zellner, Esquire of Hynum Law and avers the following: 1. On or about June 6, 2013, Plaintiff filed a Motion to Amend Complaint. 2. On or about June 12, 2013, a Rule to Show Cause was issued upon the Estate of Gayle Holtman and Enrico Holtman. 3. On or about June 13, 2013, the Rule was served upon Enrico Holtman. 4. No estate has been opened for Gayle Holtman. 5. No response to Plaintiff's Motion to Amend Complaint was received from Enrico Holtman within 20 days of service. 6. Plaintiff respectfully requests Your Honorable Court make the Rule Absolute and grant Plaintiff's Motion to Amend Complaint. WHEREFORE, Plaintiff respectfully requests this Court to grant Plaintiff's Motion to Amend Complaint and make the Rule Absolute. Date: -,/g//2 Brian K. Zellner, Esquire Attorney for Plaintiff Hynum Law Attorney ID 59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL : NO. 13-3042 MINISTRIES d/b/a • CUMBERLAND CROSSINGS, Plaintiff, • • v. • • • GAYLE HOLLMAN, Defendant, : CIVIL ACTION - LAW CERTIFICATE OF SERVICE On this day of July, 2013, I certify that a copy of the Plaintiff's MOTION TO MAKE RULE ABSOLUTE was served upon the following individual by placing the same in the United States mail, first class, postage paid, addressed as follows: Enrico Holtman 2674 N. Sherman Street York, PA 17406-2332 Brian K. Zellner, Esquire Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 Attorney for the Plaintiff IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL NO. 13-3042 MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff, V. GAYLE HOLLMAN, Defendant, CIVIL ACTION - LAW ORDER AND NOW this /dam day of 2013, upon consideration of the Plaintiff's Motion to Make Rule Absolute, it is her y ordered that said Motion is GRANTED. Plaintiff is hereby given leave to amend the Complaint and caption of the case to add Enrico Hollman as the Defendant. BY THE COURT: J. Distribution: ✓ �r n K. Zellner, Esquire, 2608 North 3rd-Street, Harrisburg, PA 17110 nrico Hollman, Pro Se, 2674 N. Sherman Street, York, PA 17406-2332 I rrl z C„ � -�Dr> N ED Y 1,C 3'c-� . > Cn i Brian K. Zellner, Esquire Hynum Law f fad PRO j fio'4j� Supreme Court ID#59262 ' 4 F 2608 North 3rd Street �1 l r Harrisburg, PA 17110 (717) 774-1357 `�`'' � ���' CO, '�' IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL NO. 13-3042 MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff, V. ENRICO HOLLMAN, 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 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 South Bedford Street Carlisle, PA 17013 Phone: (717) 249-3166 USTED HA SIDO DEMANIDADO EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de is proximos viente (20) dias despues de la notification de esta Demanda y aviso radicando personalmente o por rnedio de un abogado una comparecencia escrita y radicando en la Corte por escritosus defenses de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tornar accion como se escribe anteriormente, el caso puede proceder sin usted y un fallo por qualquier suma de dinero reclamada en la demandaa o cualquier otra reclamacion o remedio solicitado por el demandanta puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad y otros direchos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO IMMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME 0 VAYA A LA SIGUIENTE OFICINA. ESTAOFICINA PUEDE PRO VEERLE INFORMACION A CERCA DE COMO CONSEGLJTR UNABOGADO. ST USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSSIBLE QUE ESTA OFICINA LE PUEDA PRO VEER INFORMACION SOBRE AGENCIES QUE OFREZCAN SERVTCIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUECUALIFICAN. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Phone: (717) 249-3166 Brian K. Zellner, Esquire Hynum Law Supreme Court ID#59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL NO. 13-3042 MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff, V. ENRICO HOLLMAN, Defendant, : CIVIL ACTION - LAW AMENDED COMPLAINT 1. Plaintiff Cumberland Crossings is a Senior Living Community of Diakon Lutheran Social Ministries located at 1 Longsdorf Way, Carlisle, PA 17015. 2. Defendant Enrico Hollman is an adult individual who resides at 2674 N. Sherman Street, York, PA 17406-2332. 3. The Defendant's mother, Gayle Holtman, applied for admission to the Plaintiff and was admitted on June 27, 2011. 4. The Defendant on or about June 27, 2011 signed a Nursing Facility Admission Agreement. A true and correct copy of said Admission Agreement is attached hereto as Exhibit "A." 5. The Defendant's mother, Gayle Hollman, was a resident at the Plaintiff's facility from June 27, 2011 until her death on March 21, 2013. 6. The Plaintiff is owed $7,594.64 for skilled nursing services. Attached hereto as Exhibit "B" is true and correct copy of the Account Statement. COUNT I - BREACH OF CONTRACT CUMBERLAND CROSSINGS v. ENRICO HOLLMAN 7. Paragraphs 1 through 6 are incorporated herein by reference as though set forth at length. 8. On or about June 27, 2011, Plaintiff and Defendant entered into an admission agreement pursuant to which Plaintiff agreed to admit the Defendant's mother, Gayle Hollman, into its facility in consideration for Defendant's agreement to pay Plaintiff for the skilled nursing care and other services. A true and correct copy of said Admission Agreement is attached hereto as Exhibit "A." 9. Plaintiff provided skilled nursing care and other services to the Defendant's mother, Gayle Hollman from June 27, 2011 until her death. A true and correct copy of the account statement evidencing charges for the services rendered is attached as Exhibit "B." 10. The Defendant as Power of Attorney for Gayle Hollman had access to her finances. 11. The Defendant is $7,594.64 in arrears on payments to Plaintiff. Despite repeated demands by Plaintiff for payment, Defendant has failed and refused and continues to fail and refuse to pay this amount. 12. It is believed and therefore averred that the Defendant converted Gayle Hollman's funds to his use. 13. The failure to remit to Plaintiff the amount owed is a material breach of the agreement between the parties. 14. The breach, as aforesaid, has caused Plaintiff injury in the amount of$7,594.64. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against Defendant in the amount of$7,594.64; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action and pursuant to the Agreement between the parties; c. Granting Plaintiff interest at the statutory rate from June 27, 2011; and, d. Granting such other relief as the Court deems equitable and just. COUNT II – BREACH OF IMPLIED CONTRACT CUMBERLAND CROSSINGS v. ENRICO HOLLMAN In the event it is determined that no i contract between Plaintiff and Defendant as alleged in Count 1, the Plaintiff alleges as follows: 15. Paragraphs 1 through 14 are incorporated herein by reference as though set forth at length. 16. On or about June 27, 2011, thei Defendant agreed to pay Plaintiff for skilled nursing care and other services. 17. On or about June 27, 2011, Plaintiff admitted the Defendant's mother, Gayle Hollman. 18. The facts, as set forth herein, establish an implied in law and implied in fact contract. j i 19. Due to the existence of the implied in law and implied in fact contracts, Plaintiff is entitled to compensation for services rendered to the Defendant's mother, Gayle Hollman. 20. Plaintiff has demanded payment under the terms of the implied in fact and implied in law contracts by sending invoices, but Defendant has refused to make payment. 21. Plaintiff has been damaged by the refusal of Defendant to pay for the skilled nursing care and other services provided, in breach of the implied in law and implied in fact contract. WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows: a. Granting judgment for the Plaintiff and against Defendant in the amount of 7,594.64; b. Granting Plaintiff its expenses, including reasonable attorney fees and costs incurred in connection with this action; c. Granting Plaintiff interest at the statutory rate from June 27, 2011; and, d. Granting such other relief as the Court deems equitable and just. Date: –7 (mil,3 4, /,C 21-L-f - Brian K. Zellner Attorney ID 59262 Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 [717] 774-1357 . I l I MMY HANDS.0N3E HFAn D IAKON LUTHERA I SOCIAL MINISTRIES i NURSING FACMTV AD1V.17[SSION AGRERM)Ll rT L` This Nursing Facility Admission Agee ent("Agreement' r is made on this ay of �Giy� 201,1,:b� and between ,{ GC :544n ("acility"), a facility of Diakon Lutheran Social Ministries and (referred to below as"You"). A. Facility is a licensed nursing facility located in �f .---, Pennsylvania. B. You are an individual in need of the nursing services that Facility provides and You agree to be admitted to Facility for the provision of nursing services within the capability of facility. ❑ has been appointed by You through a durable Power of Attorney or Advance Directive to make admission and/or financial decisions on Your behalf (copy of document attached). OR , ❑ , has been appointed guardian by a court-to make admission and/or financial decisions on Your behalf(copl of document attached). The above-named individual shall be referred to below.as"Your legal representative". [If You have designated a"responsible party", [Your-responsible party may.execute this Agreement on Your behalf However, Your responsible party may not make health care and/or financial decisions for You unless Your responsible party also has legal authority to make such decisions as an agent under a-properly executed,power of attorney or as Your court appointed guardian.] NOW THEREFORE,in consideration of the terms and covenants contained in this Agreement, the,parties agree as follows: • I 1. Services Provided. a. Facility shall provide You with the appropriate level of nursing services and other specified items and services within the capacity and capability of the Facility. These services shall be provided as part of the daily room rate("Daily Rate")and include basic room,meals,general nursing care,activity program,housekeeping services, bedding and linens,personal hygiene supplies,and routine nursing supplies. Facility may also provide additional services("Additional Services'() upon Your request or as otherwise required by Your condition,within the capacity of Facility. You hereby acknowledge that You have been advised verbally of the Daily Rate and charges for Additional Services and that a written schedule of the Daily Rate and Additional Services has been provided to You and/or Your legal representative. b. Facility reserves the right to change the Daily Rate and the charges for Additional Services at any time. Facility shall notify You and/or Your legal representative in writ b P rE'PA S NF admission ageeman-Rev.1.07 • it r c. not less than thirty(30)days prior to any change in the Daily Rate and/or the charges for Additional Services. d. Physician services: You or Your legal'representative shall designate a physician,who must be properly licensed and must abide by applicable laws,regulations,and the policies of Facility,to be responsible for the medical evaluation of You and to prescribe a planned regimen of care. Your physician must be credentialed by Facility prior to providing services to You at Facility.You understand that in the event Your attending 'physician is not available or in an emergency,Facility may engage any licensed physician to attend to You and to render medical treatment. 2. Consent. By entering.into this Agreement,You and/or Your legal representative consent to the assessment;treatment, and care of You I by Facility within the means, capacity and capability ofFacility. 3. Payment for Services: a.._ Dail Rate. You and/or Your legal representative shall be responsible.to pay the Daily Rate of the Facility. If You are eligible for coverage under a governmental program or by a third party payor or managed care organization,Your Dally hate may be fully or. partially covered. However,You and/or Your legal.representative shall be responsible for any deductibles,required co-insurance,patient liability payments,or non-covered charges. b. Additional Services. You and/or Your legal representative shall.also'be responsible for payment of Additional Services provided to You. If You are eligible for coverage under a governmental program or by a third:party payor or managed care organization, Additional Services may be fully or partially covered.-However,You and/or Your legal representative shall be responsible for any deductibles,required co-insurance,patient liability payments,or non-covered charges. c. Payment Dates. Each month,You will receive a statement which includes two types of charges: the monthly fee due for the current month's room and board(at the Daily Rate) and-any charges for Additional Services from the previous month. The statement will also reflect all payments deposited in the bank by the last day of the previous month. All bills by Facility to You are due and payable upon receipt. Payments may be made at Facility or mailed to Facility's lockbox inl Philadelphia using the return envelope accompanying Your monthly statement. d. CollectionsfLate Payments. You and/or Your legal representative shall be responsible to pay all actual attorney's fees and costs incurred by Facility relative to the collection of any amounts ninety.(90)days past due. e. Chance in Charaes. Facility reserves the ight to increase or decrease the Daily Rate and charges for Additional Services provided to You. Facility shall provide You and/or Your legal representative with not less than thirty (3 0)days'notice prior to the expected increase or decrease. PA SNF admission agreement-Rev.1.07 f. Failure to pay for services or apply for medical assistance. In the event You and/or Your legal representative do not pay for services provided by Facility or in the event You and/or Your legal representative do not apply for medical assistance when Your resources are exhausted pursuant to Paragraph 7, You shall be discharged for nonpayment of stay. 4. Legal representative's authority. An individual executing this Agreement as a legal representative is representing that he/she has legal access to the resident's income and/or financial resources and that he/she will pay from the resident's income and/or financial resources all fees and charges for which the resident is liable under this Agreement.The legal representative assumes no financial responsibility beyond the resources of the resident. However,in the event that such legal representative misappropriates the resident's income and/or resources or otherwise illegally transfers assets,the legal representative may be liable to the Pennsylvania Department of Public Welfare and/or the Facility for the cost of care that should_have been paid for by the resident. In addition,misappropriation of funds may also result in the imposition of civil or criminal penalties against the legal representative. 5. Admission Information. a. Responsibility to provide accurate and timely information. Upon admission, and throughout Your stay,You and/or Your legal representative will notify Facility and :provide all information needed regarding Your eligibilityfor coverage by third party payors,managed care organizations, or governmental programs,-including copies of insurance cards,coverage information,verification of eligibility,etc. b. Chance in eligibility. You and/or Your legal representative must notify Facility in .writing within five(5)days of a change in your coverage status,such as Your .disenrolhnent.earollment,.failure to pay premiums or cancellation of coverage. If You and/or Your legal representative fail to provide such information,You and/or Your legal representative may be responsible for any charges or costs incurred by Facility as a result. 6. Medicare. a. Facility is a participating provider in the Medicare program. Medicare may pay for limited skilled-nursing days. Upon admission to Facility or during Your stay at Facility, if Facility expects that Medicare will not pay for the services provided to You under this Agreement,Facility shall inform.You and/or Your legal representative in writing why the services may not be covered. b. Facility shall concurrently inform You and/or Your Iegal representative of Your right to demand that Your bill be submitted to Medicare. i 7. Medical Assistance. I a. Facility is a participating provider in the Pennsylvania Medical Assistance Program. You and/or Your legal representative shall be responsible to apply for Medicaid on a timely basis if You are eligible. You and/or Your legal representative are responsible for giving Facility notice at least six(6)months in advance of the date Your resources will be PA SNF admission agreement-Rev.1.07 ! i I I exhausted. If You and/or Your legal representative do not apply for Medicaid on a timely . basis or do not provide information required by the Pennsylvania Department of public Welfare to determine Your eligibility for Medicaid,Facility may transfer or discharge You for nonpayment of stay. b. You and/or Your legal representative aIie responsible for payment of any amounts that the Pennsylvania Department of Public'Welfare or one of its local offices determines is Your contribution,or patient liability. If You and/or Your legal representative do not pay such amounts due,Facility m9y transfer or discharge You for nonpayment of stay. i c. Facility may charge for items and services not paid by Medicaid if charges are disclosed and agreed to by the parties in advancel d. Consistent with the reimbursement regulations of the Commonwealth of Pennsylvania,, residents who are or who become beneficiaries of Medicaid will be accommodated in semi-private rooms. 8. Transfers and Discharges. a. Reasons for Transfer or Discharge_, Facilit3=has the right to transfer or discharge You for medical.reasons,for Your welfare or that of other residents, or for nonpayment of stay if Facility has made reasonable efforts to collect Your outstanding amounts dust. b. Notice of Transfer or Discharge. Except in.emergency cases,Facility shall provide You •and Your legal representative with not less than thirty(30)days'written notice prior to Your transfer or discharge,.unless appropriate plans acceptable to You and/or Your legal representative are implemented sooner. c. .Discharge Plan. Facility shall provide a coordinated interdisciplinary discharge plan for You to ensure that You have a program of continuing care after discharge from Facility in accordance with Your needs. I d. ,Transfers between Facilities. If Facilityterminates this Agreement or otherwise discharges or transfers You to another health care facility,Facility shall assure that appropriate arrangements are made for Your safe and orderly transfer and that You are transferred to an appropriate place capable of meeting Your needs. Facility shall provide clinical records describing Your needs, 'including a fist of orders and medications directed by the attending plzysiciau;to the facility to which You are transferred. You may be charged for the costs of copying Your clinical records. I e. Bed Hold Poliev. Prior to Your transfer1for hospitalization oftherapeutic leave,Facility shall provide You with written notice of Your right to resume residence at Facility and Facility's bed hold policy in accordance With state law. f. Appeal and Fair Hearing for Medicare ar d Medicaid Beneficiaries. You and/or Your legal representative shall have the right to an appeal and a fair hearing with respect to Facility's decision to transfer or discharge You. PA sNF admission agreement-Rev.1.07 1. I � I • 9, Termination by Facility. a- Failure to pay. Facility may discharge,You and terminate this Agreement upon Your failure to pay for the services provided by Facility pursuant to the terms and conditions of this Agreement,including for Your failure to apply for Medicaid when eligible. Facility . shall provide You and/or Your legal representative with not less than thirty(30)days' notice of termination of this Agreement and Your discharge or transfer. i b. Closure or Destruction of Facility. Facility reserves the right to tenninatc this Agreement upon closure or destruction of Facility. In the event that Facility intends to close,Facility shall provide You and Your legal representative with thirty(30)days'written notice of intent to close.You and/or Your legal representative shall be responsible to pay all fees incurred prior to the date of termination. 10.Termination by You. (Applicable only to private pay residents.) You and/or Your legal representative may terminate this Agreement for any reason upon seven(7)days'written notice-to Facility. Except in the.case of an 'emergency transfer or death,if You and/or Your legal representative do not give the required seven(7)days'written notice,You and/or Your legal representative will be responsible for.paymerit of the Daily Rate for each day of the required notice,regardless of whether You.still resided at Facility. 11.Effect of Termination.Upon,termination of this Agreement neither party shall have any further obligations except obligations.incurted.prior to the date of termination-ar d.as otherwise set forth in this Agreement 12-Refunds. In the event of Your death,Facility shall;-refund the following amount to Your personal representative or guardian-within sixty(60) days of the date Your room is cleared of Your personal property: a. the amount of the difference between any payment made by You for monthly charges for "elder care services"(as defined below)and the cost of the"elder care services"actually provided to You. i. elder care services are services or treatment provided to meet a resident's need for personal care or health care, including, but not limited to, assistance with activities of daily living,physical!,occupational or speech therapy,and medical social services. Room and board is not included in elder care services. 13.Inventory and storage of Your personal property after death. Facility shall contact Your representative or guardian within menty-four(24)hol:rs of Your death to arrange for an inventory of Your personal property. a. If Your representative or guardian is unable to claim Your personal property within three (3)business days after Your death,Facility may place Your personal,property,in storage for up to thirty(30)days_ PA SNF admission agreement-Rev.1.07 b. If Your property is unclaimed after the storage period of thirty(30}days,Facilzty shall send notice.by certified mail stating that Your personal property will be disposed of at the end of an additional fourteen(14)day period. c. If Your personal property is unclaimed following the additional fourteen(14)day period, Facility shall dispose of the property. 14.Advance Directives.Facility has provided information to You about the Facility's policies concerning implementation of Advance Directives,and a written description of Pennsylvania law concerning Advance Directives. Facility shall comply with Your rights under state law to make decisions concerning medical care,including the.-right to accept or refuse medical or surgical treatrnent and the right to.formulate advance directives and shall document in Your . clinical record whether or not You have executed an advance directive. Facility does not condition the provision of medical care to You based on whether or not You have executed an advance directive. 15.Resident Funds. a. Written Authorization. Facility shall not require You to deposit personal funds with Facility. If You elect to deposit personal funds,upon Your and/or Your legal representative's written authorization,Facility shall hold,manage,safeguard and account for such personal funds at no additional charge to You. b. D e osit. IfYou are-a Medicare or.Medicaid beneficiary,Facility shall deposit any amount DfYour.personal funds in excess.&TiftyDollars.($50)into an account that is separate from any of Facility's operating accounts.and.shall.credit all interest earned on such separate account to such account. For.amounts less than the amounts set forth above,.Facility shall maintain such personal funds in anon-interest bearing account or petty cash fund. c. Acoountine and Records. Facility shall provide a complete and separate accounting of each Facility resident's personal funds,maintain a written record of all financial transactions involving Your personal funds deposited at Facility and afford You and/or Your legal representative reasonable access to such record. d. Disbursement U on Death. In the event of Your death,Facility shall convey Your personal funds and accounting of such funds to the individual administering Your estate, within thirty(30)days ofYour death. 16. Your Rights. Facility has provided You and/or Your legal representative with a copy of Facility's Resident Rights outlining Your legal rights,during Your stay at Facility,and You and/or Your legal representative acknowledge receiving information about Resident Rights. 17. Your Personal Property. You shall be permitted to keep and use personal clothing and possessions as space in Facility permits unless to do so would infringe upon the rights of other residents and unless medically contraindicated,as reasonably determined by Facility. Facility shall make reasonable provisions for the handling and storage of Your personal PA SNF admission agreement-Rev.2.07 clothing and possessions and provide You access to such clothing and possessions. You are advised not to have valuables such as large amounts of money,jewelry,etc. in the Facility. Facility will investigate all allegations of lost or misappropriated resident property at Facility, but will be responsible for such lost or misappropriated property only in limited circumstances. 18.Visitors. You shall-be permitted to have visitors at Facility in accordance with all applicable policies and procedures of Facility. Facility reserves'the right to limit visitors or access to You-if Facility has determined that such access maybe detrimental to Your care and well- being or in the event visitors are disruptive to other residents or the operations of Facility. Notwithstanding the foregoing,Facility shall'not restrict access to Your legal counsel or, representatives ofPennsylvania's Department of Aging. 19.Indemnification. You will defend,indemnify and hold Facility harmless from any and all claims;liabilities,damages, costs or expenses(including reasonable attorneys'fees)arising from or resulting in any manner from any of Your acts or omissions which damage or injure any person or the property of any person or of Facility. This provision does not release the Facility from any Iiabilities or duties otherwise imposed by law. 20.Miscellaneous. a. Compliance with Laws. Facility:shall comply with all applicable federal and state.laws, as maybe in effect from time to.time. b. Governing Law. This Agreement shall be governed by.and construed in accordance with. the laws of the Commonwealth ofPennsylvania,notwithstanding any conflict of laws provisions to the contrary. c. Sevetability. If any term or provision of this Agreement or the application thereof to any person or circumstance shall to any extent be invalid or unenforceable,the remainder of this Agreement or-the application of such term or provision to persons or circumstances other than those to which it is held.invalid or unenforceable shall not be affected, and each term and provision of the Agreement shall be valid and enforceable to the fullest extent permitted by law. d. Assignment. You may not assign this Agreement. e. "Waiver. The waiver by Facility of a breach of any provision of this Agreement by You shall not operate or be construed as a waiver of any subsequent breach by You. f. Notices. Any notice required or permitted to be given under this Agreement shall be deemed properly given if in writing and if mailed by regular mail in the case of Your legal representative,delivered to Your room in the case of notices to You, or to the principal office of Facility in the case of notice to Facility. The effective date of any such notice shall be the date of mailing or the date of personal delivery,whichever is applicable. The address to which notice shall be sent may be changed by a written notice given pursuant to this Paragraph. PA SNF admission ag=ment-Rev.1.07 g. Non-Discrimination. Facility shall not discriminate against You on the basis of Your sex, age,race,color,creed, national origin,sexual orientation,handicap or any other class protected by law. h. Entire Agreement. This Agreement contains the entire Agreement of the parties relating to the subject matter hereof. This Agreement supersedes and replaces in its entirety any existing agreement between You,Your legal representative and Facility regarding Your admission io Facility,and may not be waived,changed,modified,extended or discharged except by a writing executed by.the Facility and by the party against whom enforcement of any such waiver,change,modification,extension or discharge is sought. i. Change in Law. Facility reserves the right to amend-this Agreement upon thirty (30) days'written notice to You and/or Your legal representative if any change in federal,state " and local laws,regulations,policy and/or interpretation.of the same,shall impair the continuing validity_and/or eil'ectiveiiess of any material provisions of this Agreement. j. Headings. The headings of the Paragraphs hereof are for convenience only and shall not control or affect the meaning or construction or_Emit the scope or intent of any of the provisions of this Agreement. k. Acknowledgment of Receipt of Resident Handbook and Notice of-Privacy Practices. You aclmowledge receipt of Facility's Resident Handbook and HIPAA Ndice of Privacy Practices. .BY SIGNING BELOW,YOV ACKNOWLEDGE THAT'YOU HAVE READTET FOREGOING AGREEMENT AND THAT YOU HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT THE AGREEMENT. IN WITNESS WHEREOF,the parties have executed this Agreement as of the date first above written. FACILITY RESIDENT OR RESIDENT'S LEGAL REPRESENTATIVE OR RESIDENT'S RESPONSIBLE PARTY By: By:'� �� Name ) DIJCZ6 71 � Name(printed)_4—L46" ame(printed) 4—L4 'i" ff9/��'�'� t PA SNF admission agreement-Rev.1.07 STATEMENT page: 1 of 1 - � � 1AK 0 N. Y2^��LiC•!<= tri)S��...f'::( ;�Jd�A�i^Y.:�s;li.At:..:.:•'::<:.:.:.tiv.A.::�. - .a.�f:}]t::��£�;i��. Lu'r.H*FR!-N'$3G1A.L MIN tSTIU.FS 130410 621CCNC 403131/2013 Cumberland Crossings Retirement Community 1 Longsdorf Way -- -: =<� atQ.tia3: �1. .MAC 1 Carlisle PA 17015 7623 ,�,... .u�:�? r,.,:_ � '!0..�... Q Facility#(717)245-9941 ,:-- .;>., ' . �k.�:.z =; - Business Office#(717)240-6040 4/23/2013 $7,594.64 Raphael Balthazar 141.Tower Circle Holtman, Gayte R Carlisle, PA 17013 Please make check payable to Diakon Lutheran Social Ministries Gayle R Holtman Cumberland Crossings Retirement Community 03/31/2013 Raphael Balthazar _ ,.<: _ _�- tA�: .. '-yam. 'M =-.Y'-'�:'-'�tr•:��^ ,.✓,� S •�%�':: Balahc r <.•r 1.<.-. .Y.��.,^•L.,t c-na v:-.<w ...an^�.�[ '.-_.�'� ...-T - l:t• :''Y-%3'..: - �'':+ �':FS F._C3-w F.i ti.••-.. - -i:'tSt+ -!-=•,C�.-....s�.aS ri::�1�:T:. - '�.. =From_.t.:.::<_ �T#trou l���s�:�-:�,.�-....-::� - :.-� s�' w:C edits. -RESIDENT RESPObJSI.BI FTY 2/28/2013 Balance Forward $7,626.00 x01/2013 2/14/2013 Resident Liability(Feb) .00 -96.3 ?10112013 03/1512013 Maintenance Service Charge 1.00 Unit 65.0 'OTAL BALANCE DUE $7,594.64 EXHIBITA VERIFICATION I ; 944;ereby state that I am the authorized representative of the Plaintiff in this action and that the statements of fact made in the foregoing Complaint are true and correct to the best of my information and belief. The undersigned understands that the statements herein are made subject to the penalties of 18 Pa. Cons. Stat. Ann. $ 4904 relating to unsworn falsification to authorities. Date: S� �- Printed Name: Title: CERTIFICATE OF SERVICE On this 15th day of July, 2013, I certify that a copy of the foregoing Notice of Deposition was served upon the following by facsimile or email and placing the same in the United States mail, first class, addressed as follows: Enrico Hollman 2674 N. Sherman Street York, PA 17406-2332 B--, CC, /Z -- Brian K. Zellner, Esquire Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 r is. Brian UK. Z i er, Esquire ,�" Attorney ID#59262 fr -3 � 2608 North 3rd Street Harrisburg, PA 17110 717-774-1357 717-774-135711 Attorneys for Plaintiff DIAKON LUTHERAN SOCIAL IN THE COURT OF COMMON PLEAS MINISTRIES d/b/a CUMBERLAND CUMBERLAND CO., PENNSYLVANIA CROSSINGS, Plaintiff NO. 13-3042 V. CIVIL ACTION - LAW ENRICO HOLLMAN, Defendant PRAECIPE TO ENTER DEFAULT JUDGMENT TO THE PROTHONOTARY: Kindly enter judgment in favor of Plaintiff and against Defendant, Enrico Hollman, in the amount of $7,594.64, plus costs. A Ten-Day Notice of Taking Default Judgment was served on the Defendant on or about August 22, 2013. A copy of the transmittal letter and Notice is attached hereto as Exhibit A. st64-16C'' Brian K. Zellner, Esquire Attorney for Plaintiff Date: December 2, 2013 S 11).SO �l �t� Lii ç\\ 5L Ra (&I HYNUM LAW 2608 NORTH 3`D STREET - HARRISBURG, PA 17110 PHONE [717j 774-1357 FAX [7171 774-0788 August 22, 2013 Enrico Holtman 2674 N. Sherman Street York, PA 17406-2332 RE: Diakon Lutheran Social Ministries d/b/a Cumberland Crossings v. Enrico Holtman Dear Mr. Holtman: Enclosed please find an Important Notice regarding the above-referenced matter. Sinc rely, it/ D ri Pletz,Paralegal Enclosure • EXHIBIT 1 A Brian K. Zellner,Esquire Hynum Law Supreme Court ID#59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA DIAKON LUTHERAN SOCIAL : NO. 13-3042 MINISTRIES d/b/a CUMBERLAND CROSSINGS, Plaintiff, v. ENRICO HOLLMAN, Defendant, : CIVIL ACTION — LAW TO: Enrico Hollman 2674 N. Sherman Street York, PA 17406-2332 Date of Notice: August 22, 2013 IMPORTANT NOTICE 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 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 IMPORTANT RIGHTS. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle,PA 17013 Phone: (717) 249-3166 4,, /C.` Brian K. Zellner, Esquire HYNUM LAW Supreme Court ID #59262 2608 N. Third Street Harrisburg, PA 17110 (717) 774-1357 Attorney for the Plaintiff • CERTIFICATE OF SERVICE On this 2nd day of December, 2013, I certify that a copy of the foregoing document was served upon the following Defendant by placing the same in the United States mail, first class, addressed as follows: Enrico Hollman 2674 North Sherman Street York, PA 17406-2332 (C., Brian K. Zellner, Esquire Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 DIAKON LUTHERAN SOCIAL IN THE COURT OF COMMON PLEAS MINISTRIES d/b/a CUMBERLAND CUMBERLAND CO., PENNSYLVANIA CROSSINGS, Plaintiff NO. 13-3042 v. CIVIL ACTION - LAW ENRICO HOLLMAN, Defendant RULE 236 NOTICE TO: Enrico Holtman Notice is given that Judgment in the amount of $7,594.64 in the above captioned matter has been entered against you on ....bee 3 /,j 7\,. ,r x.- Pro notary By: Clerk or Deputy If you have any questions concerning the above case, please contact: Brian K. Zellner, Esquire Attorney or Filing Party 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 DIAKON LUTHERAN SOCIAL MINISTRIES d/b/a CUMBERLAND CROSSINGS, ENRICO HOLLMAN, Plaintiff Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PA c-, = cm — 3 DLI a trl Ca = rn = : NO. 13-1=1:ig v) r"- _< Xr. r— < c:, ›. c-, = cp ..„-- - ---- : CIVIL ACTION - LAW 2,10" .!Yr CA) PLAINTIFF'S MOTION TO COMPEL DEFENDANT ENRICO HOLLMAN TO ANSWER THE INTERROGATORIES IN AID OF EXECUTION AND NOW comes, Plaintiff, Diakon Lutheran Social Ministries d/b/a Cumberland Crossings, by and through its Counsel, Brian K. Zellner, Esquire of Hynum Law and avers the following: 1. On or about December 3, 2013, Plaintiff entered judgment against Defendant Enrico Hollman. 2. On or about December 9, 2013, Plaintiff addressed Interrogatories to the Defendant. 3. Plaintiffs Counsel had requested that the Defendant Enrico Hollman provide Answers to its Interrogatories by letter dated December 9, 2013. 4. Plaintiff did not receive Answers to its Interrogatories by thirty (30) days. 5. To date, Defendant has not answered the Interrogatories. 6. Plaintiff respectfully requests your Honorable Court to compel Defendant Enrico Hollman to Answer the Interrogatories. WHEREFORE, Plaintiff respectfully requests this Court to grant Plaintiffs Motion to Compel Defendant Enrico Hollman to Answer the Interrogatories. Date: an K. ellner, Esquire Attorney for Plaintiff Hynum Law Attorney Id. 59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 DIAKON LUTHERAN SOCIAL MINISTRIES d/b/a CUMBERLAND CROSSINGS, ENRICO HOLLMAN, Plaintiff v. Defendant : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, PA : NO. 13-3402 : CIVIL ACTION - LAW CERTIFICATE OF SERVICE On this 25th day of July, 2014, I certify that a copy of the MOTION TO COMPEL DEFENDANT TO ANSWER INTERROGATORIES IN AID OF EXECUTION was served upon the following Defendant Enrico Hollman by placing the same in the United States mail, first class, postage paid, addressed as follows: Enrico Hollman 2674 N. Sherman Street York, PA 17406-2332 S Brian K. Zellner, Esquire Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 DIAKON LUTHERAN : IN THE COURT OF COMMON PLEAS OF SOCIAL MINISTRIES d/b/a : CUMBERLAND COUNTY, PENNSYLVANIA CUMBERLAND CROSSINGS, : Plaintiff v. : CIVIL ACTION — LAW ENRICO HOLLMAN, Defendant : NO. 13-3042 CIVIL TERM IN RE: PLAINTIFF'S MOTION TO COMPEL DEFENDANT ENRICO HOLLMAN TO ANSWER THE INTERROGATORIES IN AID OF EXECUTION ORDER OF COURT AND NOW, this 4th day of August, 2014, upon consideration of Plaintiffs Motion To Compel Defendant Enrico Hollman To Answer the Interrogatories in Aid of Execution, a Rule is hereby issued upon Enrico Hallman to show cause why the relief requested should not be granted. RULE RETURNABLE within 20 days of service. Brian K. Zellner, Esq. Hynum Law Office 2608 North 3rd Street Harrisburg, PA 17110 Attorney for Plaintiff Enrico Hollman 2674 N. Sherman Street York, PA 17406-2332 Defendant, pro Se :rc fri_x_ti-c(_, 8 iy BY THE COURT, eel,. Peck, J. 1 4 - Brian K. Zellner, Esquire Hynum Law Supreme Court ID #59262 2608 N. Third Street Harrisburg, PA 17110 (717) 774-1357 DIAKON LUTHERAN SOCIAL MINISTRIES d/b/a CUMBERLAND CROSSINGS Plaintiff, v. ENRICO HOLLMAN, Defendant, PLAINTIFF' : IN THE COURT OF COMMON PLEAS : CUMBERLAND COUNTY, : PENNSYLVANIA : NO. 13-3042 : CIVIL ACTION - LAW S PETITION FOR CONTEMPT plc° rn CD •••• AND NOW comes, Plaintiff, Diakon Lutheran Social Ministries d/b/a/ Cumberland Crossings, by and through its Counsel, Brian K. Zellner, Esquire of Hynum Law and avers the following: 1. On or about December 13, 2013, Plaintiff entered judgment against the Defendant. 2. On or about July 5, 2014, Plaintiff addressed Interrogatories In Aid of Execution to the Defendant. 3. The Plaintiff file a Motion to Compel Answers from the Defendant to the Interrogatories. 4. An Order of Court was entered on August 4, 2014 which granted Plaintiff's Motion to Compel and gave the Defendant 10 days to Answer Plaintiff's Interrogatories. 5. On August 6, 2014, the Plaintiff served the Order on the Defendant. 6. To date, Plaintiff's Counsel has not received Answers from the Defendant. 7. The Defendant has willfully failed to abide by the August 4, 2014 Order of Court because the Plaintiff has not received Answers to the Interrogatories. WHEREFORE, Plaintiff respectfully requests this Court find the Defendant in Contempt. Date: It Resp ctfully Submitted: Brian K. Zellner, Esquire Hynum Law Attorney ID. No. 59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 Attorney for the Plaintiff CERTIFICATE OF SERVICE I, Brian K. Zellner, Esquire, do hereby certify that on this, the f day of September, 2014, I served a true and correct copy of the foregoing Petition for Contempt and proposed Order of Court upon the following individual by way of First Class Mail, Postage Prepaid: Dated: Enrico Holtman 2674 N. Sherman Street York, PA 17406-2332 Br4TaK. Zellner, Esquire Hynum Law Attorney ID. No. 59262 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 Attorney for the Plaintiff it DIAKON LUTHERAN SOCIAL : IN THE COURT OF COMMON PLEAS MINISTRIRES d/b/a, CUMBERAND : CUMBERLAND COUNTY, CROSSINGS, : PENNSYLVANIA Plaintiff, : NO. 13-3042 -7,) p1 crn : mc V. : cn!� r _ ENRICO HOLLMAN, • Defendant, : CIVIL ACTION - LAW ORDER AND NOW,this &Iv day of 'u , 2014, upon consideration of the Plaintiff's Petition for Contempt against the Defendant, it is hereby ordered that a Hearing is scheduled for /3 , 2014 at /0=60 a.m./p..r. in Courtroom 5--at the Cumberland County Courthouse, Carlisle Pennsylvania. BY THE COURT: J. ribution: K. Zellner, Esquire, 2608 North 3rd Street, Harrisburg, PA 17110 Enrico Hollman, Pro-Se, 2674 N. Sherman Street, York, PA 17406-2332 �es tL !vT4ty Brian K. Zellner,Esquire j " ' e" Hynum Law Supreme Court ID#59262 2608 North 3`d Street Harrisburg, PA 17110 (717)774-1357 DIAKON LUTHERAN SOCIAL : IN THE COURT OF COMMON PLEAS MINISTRIES d/b/a CUMBERLAND CUMBERLAN COUNTY, CROSSINGS, PENNSYLVANIA Plaintiff, NO. 13-3042 V. ENRICO HOLLMAN, Defendant, CIVIL ACTION - LAW PRAECIPE TO WITHDRAW To the Prothonotary: Please withdraw the Plaintiff's Petition for Contempt that was filed on September 16, 2014. Date: 1°' 3 y 4HfJM LAW Brian K. Zellner, Esquire Supreme Court ID #59262 2608 North 3`a Street Harrisburg, PA 1710 (717) 774-1357 Email: bzellner@hynumpc.com Attorneys for Plaintiff 1 + ) l CERTIFICATE OF SERVICE On this /3 day of dc%.4a-1 2014, I certify that a copy of the foregoing document was served upon the following individuals by placing the same in the United States mail, first class, postage paid, addressed as follows: Enrico Hollman 2674 N. Sherman Street York, PA 17406-2332 Brian K. Zellner, Esquire Hynum Law 2608 North 3rd Street Harrisburg, PA 17110 (717) 774-1357 Attorney for the Plaintiffs DIAKON LUTHERAN IN THE COURT OF COMMON PLEAS OF SOCIAL MINISTRIES CUMBERLAND COUNTY, PENNSYLVANIA d/b/a CUMBERLAND CROSSINGS, Plaintiff V. CIVIL ACTION—LAW ENRICO HOLLMAN, Defendant NO. 13-3042 CIVIL TERM IN RE: PLAINTIFF'S PETITION FOR CONTEMPT ORDER OF COURT AND NOW, this IP day of October, 2014, upon consideration of Plaintiff's Praecipe To Withdraw Plaintiff's Petition for Contempt, and neither party having appeared for the hearing on October 13, 2014 on the petition for contempt, the petition for contempt is hereby withdrawn. BY THE COURT, 0'�u— Chris(ylee L. Peck, J. MCC i Brian K. Zellner, Esq. 2608 North Third Street r -t3 Harrisburg, PA 17110 Attorney for Plaintiff 'G-yc °D Enrico Hollman 2674 N. Sherman Street York, PA 17406-2332 Defendant, pro Se :rc 4"e5 /6)// Arc