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HomeMy WebLinkAbout13-5142 COMMONWEALTH OF PENNSYLVANIA COURT OF COMMON PLEAS NOTICE OF APPEAL Judicial District, County Of FROM MAGISTERIAL DISTRICT JUDGE JUDGMENT CO MMON PLEAS No. 3 '� s� L/� �Jv �/ NOTICE OF APPEAL Notice is given that the appellant has filed in the above Court of Common Pleas an appeal from the judgment rendered by the Magisterial District J ge on the date and in the case referenced below. //� a ,J — U � , 3 6 3 Y' NAM OF AP EL NT MAG. DISJ0. 1�. U-- NAME OF MDJ ADDRESS OF AP LLAN ' CITY STATE ZIP CODE G 7 DATE OF JUDG IN THE CASE OF (Pla (Defendant)' '� V � L �lrrd VS DOCKET No. SIGNATURE OF APPELLANT OR ATTORNEY OR AGENT J - G a This block will be signed ONLY when this notation is required under Pa. If appellant was Claimant (see Pa. R.C.P.D.J. No. 1001(6) in action R.C.P.D.J. No. 1008B. This Notice of Appeal, when received by the Magisterial District Judge, will before a Magisterial District Judge, A COMPLAINT MUST BE FILED operate as a SUPERSEDEAS to the judgment for possession in this case. within twenty (20) days after filing the NOTICE of APPEAL. Signature of Prothonotary or Deputy PRAECIPE TO ENTER RULE TO FILE COMPLAINT AND RULE TO FILE (This section of form to be used ONLY when appellant was DEFENDANT (see Pa.R.C.P.D.J. No. 1001(7) in action before Magisterial District Judge. IF NOT USED, detach from copy of notice of appeal to be served upon appellee. PRAECIPE: To Prothonotary Enter rule upon A appellee(s), to file a complaint in this appeal L/ 1 N.Y.; of appellee(s) (Common Pleas No. -3 la 7 C)'y, I ) within twenty (20) days after service of rule or suffer entry of judgment of non pros. Signature of appellant or attomey or agent RULE: To .�l— fl ,� n�m appellee(s) - Name of app lee(s) (1) You are notified that a rule is hereby entered upon you to file a complaint in this appeal within twenty (20) days after the date of service of this rule upon you by personal service or by certified or registered mail. (2) If you do not file a complaint within this time, a JUDGMENT OF NON PROS MAYBE E ERED AGAINST YOU. (3)) /-3 Thhe date of service of this rule if service was by mail is the date of the mailing. Date: ? , 20/ VINVAI SNN 7 ,,t iNnoo Qil V 183 ••` ` Signof Prothonotary or Deputy 8 l =Z1 WJ £- 83S EIR THE YOU MUST INCLUDE A COPY OF NO p F UDIGMENTITRANSCRIPT FORM WITH THIS NOTICE OF APPEAL. � f If r e� G 1°i O P P �. � i r j., AOPC 312 -05 cask COMMONWEALTH OF PENNSYLVANIA Notice of Judgment/Transcript Civil COUNTY OF CUMBERLAND Case Mag. Dist. No: MDJ- 09 -3 -03 Claremont Nursing & Rehab Ctr MDJ Name: Honorable Susan K. Day V. Address: 229 Mill Street Patricia Haverstock P.O. Box 167 Mount Holly Springs, PA 17065 Telephone: 717-486-7672 Patricia Haverstock Docket No: MJ- 09303 -CV- 0000020 -2013 2307 New York Ave. Case Filed: 2/6/2013 Camp Hill, PA 17011 Disposition Summary Docket No Plaintiff Defendant Disposition Disposition Date MJ- 09303 -CV- 0000020 -2013 Claremont Nursing & Rehab Ctr Patricia Haverstock Judgment for Plaintiff 08/05/2013 Judgment Summary Participant Joint /Several Liability Individual Liability Amount Claremont Nursing & Rehab Ctr $0.00 $0.00 $0.00 Patricia Haverstock $0.00 $8,451.75 $8,451.75 Judgment Detail (*Post Judgment) In the matter of Claremont Nursing & Rehab Ctr vs. Patricia Haverstock on 8/05/2013 the judgment was awarded as follows: Judgment Component Joint/Several Liability Individual Liability Deposit Applied Amount Civil Judgment $0.00 $8,253.00 $8,253.00 Filing Fees $0.00 $161.50 $161.50 Server Fees $0.00 $37.25 $37.25 Grand Total: $8,451.75 ANY PARTY HAS THE RIGHT TO APPEAL WITHIN 30 DAYS AFTER THE ENTRY OF JUDGMENT BY FILING A NOTICE OF APPEAL WITH THE PROTHONOTARYICLERK OF COURT OF COMMON PLEAS, CIVIL DIVISION. YOU MUST INCLUDE A COPY OF THIS NOTICE OF JUDGMENT /TRANSCRIPT FORM WITH YOUR NOTICE OF APPEAL. . EXCEPT AS OTHERWISE PROVIDED IN THE RULES OF CIVIL PROCEDURE FOR MAGISTERIAL DISTRICT JUDGES, IF THE JUDGMENT HOLDER ELECTS TO ENTER THE JUDGMENT IN THE COURT OF COMMON PLEAS, ALL FURTHER PROCESS MUST COME FROM. -THE COURT OF COMMON PLEAS AND NO FURTHER PROCESS MAY BE ISSUED BY THE MAGISTERIAL DISTRICT JUDGE. UNLESS THE JUDGMENT IS ENTERED IN THE COURT OF COMMON PLEAS, ANYONE INTERESTED IN THE JUDGMENT MAY FILE A- - REQUEST FOR ENTRY OF SATISFACTION WITH THE MAGISTERIAL DISTRICT JUDGE IF THE JUDGMENT DEBTOR PAYS IN FULL, SETTLES, OR OTHERWISE COMPLIES WITH THE JUDGMENT. E3 1 Date Magisterial District Judge Susan K. Day s y I certify that this is a true and correct copy of the record of the proceedings containing the judgment.. Date: Magisterial District Judge . MDJS 315 Page 1 of 2 Printed: 08/05/2013 11:07:23AM Claremont Nursing & Rehab Ctr Docket No.:. MJ- 09303 -CV- 0000020 -2013 V. Patricia Haverstock Participant List. Plaintiff(s) Claremont Nursing & Rehab Ctr 1000 Claremont Rd Carlisle, PA 17013 Defendant(s) Patricia Haverstock .. __ __ •aa :. _ ,�.., ..� _: - - -�.:. _..�.: .:. - .:. �. - .,mss,.• . - S Camp Hill, PA 17011 } e f iY ._. - V.w�.G. ." � -_. -� .-mac .. •_ .. -. -.. .. _s�.z _ .�. -_.. .•_ =_ .i.t'�^- 'inq,-- ..._.- �-- .�v -�sv _- i.,s-..v^...._ - mac_ ✓-r -�. - .+s-.a-- �- -.x-.n -sip.. _� .�.Ytr MDJS 315 Page 2 of 2 Printed: 08/05/2013 11:07:23AM COMMONWEALTH OF PENNSYLVANIA Rescheduling Notice COUNTY OF CUMBERLAND �: "' Mag. Dist. No: MDJ- 09 -3 -03 Claremont Nursing & Rehab Ctr MDJ Name: Honorable Susan K. Day V. Address: 229 Mill Street Patricia Haverstock P.O. Box 167 Mount Holly Springs, PA 17065 Telephone: 717-486-7672 Patricia Haverstock Docket No: MJ- 09303 -CV- 0000020 -2013 2307 New York Ave. Case Filed: 2/6/2013 Camp Hill, PA 17011 f' 0 . A civil complaint has been filed against you in the above captioned case. A Civil Action Hearing was previously scheduled on July 1, 2013 / 10:00 AM. It has been rescheduled to be held on /at: Date: Monday, August 5, 2013 Place: Magisterial District Court 09 -3 -03 229 Mill Street Time: 10:00 AM P.O. Box 167 Mount Holly Springs, PA 17065 717- 486 -7672 Continuance requested by Patricia Haverstock Reason: Other Notice To Defendant If you intend to enter a defense to this complaint, you should so notify this office immediately at the above telephone number. You must appear at the hearing and present your defense. Unless you do, judgment may be entered against you by default. If you have a claim against the plaintiff which is within magisterial district judge jurisdiction and which you intend to assert at the hearing, you must file it on a complaint form at this office at least five days before the date set for the hearing. Pursuant to Pa.R.C.P.D.J. No. 342(8)(2), no claim by the defendant will be permitted in a supplementary action filed for failure of judgment creditor to enter satisfaction. Notice To Plaintiff Pursuant to Pa.R.C.P.D.J. No. 318, you or your attorney will be notified if the defendant gives notice of his/her intention to defend. If you are 'disabled and'require a "r"easonable' accommodation to gain access to the Magisterial District Court and its services, please contact the Magisterial District Court at the above address or telephone number. We are unable to provide transportation. You can make case payments online through Pennsylvania's Unified Judicial System web portal. Visit the portal at httpJ /ujsporta1.pacourts.us to make a payment. MDJS 308 1 Printed: 06/27/2013 8:11:04AM _ n CMS NOV ITAS `� CENTERS FOR MEDICARE &MEDICAID SERVICES ��(( D sou T IoNS MEDICARE SGT July 1, 2013 , 9 - ;7 Patricia Haverstock 2307 New York Ave. Camp Hill, PA 17011 -7316 Subject: Beneficiary: Patricia Haverstock Health Insurance Claim No.: 194- 28 -9718A Provider: CLAREMONT NURSING AND REHABILITATION Date of Service: October 01 -15, 2010 Dear Patricia Haverstock: This response is in regards to the inquiry we received about the above claim. It is stated that you are being billed for charges that are not patient liable. Medicare has reviewed the claim and we show the claim was paid in full. There are no patient liable amounts on the claim. I have informed the provider of this information and advised not to bill you. I am sorry for any inconvenience this may have caused you. If you have any additional questions, please call 1- 800 - MEDICARE (i-800-633-4227). If you are hearing impaired or speech impaired, call the TTY/TDD line toll -free at 1- 877 - 486 -2048. Sincerely, Danny D. Rosario Customer Service Representative Novitas Solutions 1 800 Center Street Camp Hill, PA 17089 www.novitas- solutions.com INNOVATION IN ACTION A CMS CONTRACTOR • ISO 9001 -2008 CERTIFIED LH059 (R1 -13) h PR ONO- O Tk' I 2013 SEP - 3 PH 10 CUMBERLAND COUNTY PENNSYLVANIA PROOF OF SERVICE OF NOTICE OF APPEAL AND RULE TO FILE COMPLAINT (This proof of service MUST BE FILED WITHIN TEN (10) DAYS AFTER filing of the notice of appeal. Check applicable boxes.) COMMONWEALTH OF PENNSYLVANIA COUNTY OF Lu��r j ; ss AFFIDAVIT: I hereby (swear) affirm) that I served ❑ a copy of the Notice of Appeal, Common Pleas No. upon the Magisterial District Judge designated therein on (date of service), 20 ❑ by personal service ❑ by (certified) (registered) mail, sender's receipt attached hereto, and upon the appellee, (name) , on CZC,"" - /t' 0 1 — 20 13 []by personal service❑ by (certified) (registered) mail, sender's receipt attached hereto. (SW O N) (AFFIRMEDLANq SUB CRIBED BEFORE ME THIS GG DAY OF 0 t C 3 Sig at ,e f o icial be re w m affidavit was made Signature of aft!ant U D Title of official My commission expires on , 20 � lh r ,q, aJm. 2N4 AOPC 312A - 05 Pennsylvania Supreme Court of Cour ofCommo leas For Prothonotary Use Only: C if Cover�Sheet Docket No: l�f Si , CU B RLNb /�p� County — ! /U The information collected on this form is used solely for court administration purposes. This fibrin does not supplement or replace the filing and service of leading,or other papers as required by law or rules of court. Commencement of Action: S [E Complaint 0 Writ of Summons Petition Transfer from Another Jurisdiction ❑I Declaration of Taking E C Lead Plaintiff's Name: Lead Defendant's Name: CLAREMONT NURSING & REHABILITATION CENTER PATRICIA HAVERSTOCK T Dollar Amount Requested: C!within arbitration limits I Are money damages requested? EM Yes a No (check one) Qoutside arbitration limits O N Is this a Class Action Suit? I7 Yes El No Is this an MDJAppeal? X; Yes No A Name of Plaintiff/Appellant's Attorney: Steven M. Montresor, Esq. 0 Check here if you have no attorney(are a Self-Represented [Pro Se] Litigant) Nature of the Case: Place an"X"to the left of the ONE case category that most accurately describes your PRIMARY CASE. If you are making more than one type of claim,check the one that you consider most important. TORT(do not include Mass Tort) CONTRACT(do not include Judgments) CIVIL APPEALS 0 Intentional C' Buyer Plaintiff Administrative Agencies 0 Malicious Prosecution 0 Debt Collection: Credit Card 0 Board of Assessment 1I.1 Motor Vehicle Debt Collection: Other I_3 Board of Elections ❑ Nuisance Nursing Facility 0 Dept.of Transportation S _l Premises Liability �] Statutory Appeal:Other 0 Product Liability(does not include IJ Employment Dispute: mass tort) E I_? Slander/Libel/Defamation Discrimination C �� Other: ice! Employment Dispute:Other U Zoning Board �-� Other: T I Other: O MASS TORT IJ Asbestos N 7 Tobacco 0 Toxic Tort-DES 0 Toxic Tort-Implant REAL PROPERTY MISCELLANEOUS u Toxic Waste 0 Ejectment I—I Common Law/Statutory Arbitration B h Oter: — 0 Eminent Domain/Condemnation ❑ Declaratory Judgment 7 Ground Rent 0 Mandamus 11 Landlord/Tenant Dispute 0 Non-Domestic Relations 0 Mortgage Foreclosure:Residential Restraining Order PROFESSIONAL LIABLITY J Mortgage Foreclosure: Commercial 0 Quo Warranto El Dental -i Partition 11' Replevin 0 Legal L--I Quiet Title IJ Other: 0 Medical 0 Other: Wi Other Professional: Updated 1/1/2011 302776v1 ma w rrl m to =M ::o -0 00 r- IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY,PENNSYLVANIA CLAREMONT NURSING AND ., REHABILITATION CENTER, W . r.? 1000 Claremont Road ~i Carlisle, PA 17013 No.: 13-5142 Plaintiff, CIVIL ACTION V. PATRICIA HAVERSTOCK, 2307 New York Avenue Camp Hill, PA 17011 NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, 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. Lawyer Referral Service Cumberland County Bar Association 32 South Bedford Street Carlisle,PA 17013 Telephone: (717) 249-3166 302502vl Steven M. Montresor Attorney ID #74244 Latsha Davis & McKenna 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 Attorneys for Plaintiff, Claremont Nursing smontresor @ldylaw.com and Rehabilitation Center IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY,PENNSYLVANIA CLAREMONT NURSING AND REHABILITATION CENTER, 1000 Claremont Road Carlisle, PA 17013 No.: 13-5142 Plaintiff, CIVIL ACTION V. PATRICIA HAVERSTOCK, 2307 New York Avenue Camp Hill, PA 17011 COMPLAINT AND NOW COMES, Plaintiff, Claremont Nursing and Rehabilitation Center, by and through its attorneys, Latsha Davis & McKenna, P.C. and files the within Complaint against Defendant Patricia Haverstock and in support thereof, avers as follows: 1. Plaintiff, Claremont Nursing and Rehabilitation Center(hereinafter"Claremont"), is a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with a principal place of business at 1000 Claremont Road, Carlisle, Pennsylvania, 17013. 3025020 2. Plaintiff Claremont owns and operates a skilled nursing home located at 1000 Claremont Road, Carlisle, Pennsylvania, 17013. 3. Defendant, Patricia Haverstock(hereinafter"Ms. Haverstock") is an adult individual who currently resides at 2307 New York Avenue, Camp Hill, PA 17011. 4. On or about August 23, 2011, Claremont agreed to accept Ms. Haverstock as a resident and to provide her living accommodations and skilled nursing services. 5. At the time of admission, Ms. Haverstock executed an Admission and Financial Agreement ("Agreement"). A true and correct copy of the Agreement ("Agreement") is attached as Exhibit"A" and is incorporated by reference as if set forth at length. 6. At all times relevant, Claremont provided skilled nursing services to Ms. Haverstock in accordance with the Admission Agreement. 7. Ms. Haverstock failed to pay Claremont for the nursing care services she received from Claremont. 8. Ms. Haverstock had a contractual duty to compensate Claremont for the nursing care services it provided to Ms. Haverstock from her assets and resources. 9. A balance in the amount of$8,253.00, plus interest is currently due and owing to Claremont for the nursing care services that it provided to Ms. Haverstock. True and correct copies of the monthly invoices are attached hereto as Exhibit`B" and are incorporated by reference as if set forth at length. COUNT I—BREACH OF CONTRACT 10. Paragraphs 1 through 9 above are incorporated herein by reference as if fully set forth at length. 11. Claremont and Ms. Haverstock entered into an Admission and Financial Agreement as more fully set forth above. 302502v1 2 12. The Agreement states: "Private Resident Charges. You are responsible for paying all charges assessed by the Facility, according to the Schedule of Fees in effect at the time services or products are provided. The Facility will assist you in applying for and obtaining additional benefits, in which you may be eligible, to cover the cost of your care at the Facility." See Exhibit"A,"p. 21. 13. At all times relevant, Claremont provided living accommodations and nursing care services to Ms. Haverstock. 14. Ms. Haverstock has an overdue balance on his account with Claremont in the amount of$8,253.00. 15. Claremont demanded payment from Ms. Haverstock of the outstanding balance on Ms. Haverstock's account. 16. The failure of Ms. Haverstock to pay the outstanding balance on her account with Claremont constitutes a breach of the Agreement. 17. The Agreement provides that in the event Claremont retains an attorney to recover an outstanding balance, the nursing facility resident is liable for attorney fees and costs. See Exhibit"A,"p. 21-22. 18. Estimated attorneys' fees in this matter will be $2,500.00. 19. The Agreement permits Claremont to assess late charge of 1.5%per month of the outstanding balance. See Exhibit"A,"p. 27. 20. As of August 7, 2013, the late charges on this account total $2,723.60. WHEREFORE, Plaintiff, Claremont Nursing and Rehabilitation Center, demands judgment in its favor and against Defendant, Patricia Haverstock, in the amount of$8,253.00 together with attorneys' fees, costs and any other relief the Court may deem just and equitable. 3o2so2v] 3 COUNT II—QUANTUM MERUIT 21. Paragraphs 1 through 20 above are incorporated herein by reference as if fully set forth at length. 22. Claremont has demanded payment in full for the nursing care services which it provided to Ms. Haverstock, and has not received payment for the same. 23. Claremont is entitled to receive payment in full for the reasonable value of the nursing care services it provided to Ms. Haverstock. 24. To the extent Ms. Haverstock has been cared for by Claremont and has not paid Claremont for that care, she has been unjustly enriched. 25. The reasonable value for services rendered to Ms. Haverstock is $8,253.00. WHEREFORE, Plaintiff, Claremont Nursing and Rehabilitation Center, demands judgment in its favor and against Defendant, Patricia Haverstock, in the amount of$8,253.00 together with any other relief the Court may deem just and equitable. Respectfully submitted, LATSHA DAVIS &McKENNA, P.C. Dated: - 3 By: Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 smontresor@ldylaw.com Attorneys for Plaintiff, Claremont Nursing and Rehabilitation Center 302502v1 4 VERIFICATION I, Scott Sowers, hereby verify that I am the Chief Financial Officer for Claremont Nursing and Rehabilitation Center; that I am authorized to make the within Verification; and the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: Scott Sowers, Chief Financial Officer 302502v1 Sep. 20. 2013 4: 11PM CLAREMONT BUSINESS OFFICE No. 1896 P. 6 VERIFICATION I, Scott Sowers,hereby verify that I am the Chief Financial Officer for Clazemont Nursing and Rehabilitation Center;that I am authorized to make the within Verification; and the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904,relating to unsworn falsification to authorities. Dated: I s_ Scott Sowers, Chief Financial Officer 302502v1 1000 Claremont Road � u� t Carlisle,PA 17013-8805 ,:. Main(717)243-2031 Fax(717)240-1952 *habilitd tion'Center ADMISSION AND FINANCIAL AGREEMENT /d This Nursing Facility Admission and Financial Agreement is entered into this � day of _5. by and between Claremont Nursing and Rehabil� atio Center ("Facility") and r`C 14cltq k.of etk ("You"), or , ("Your Responsible Party"). ARTICLE 1 Definitions A:�reer?7eftt Refers to this Nursing.Facility Admissions and Financial.Agreement. Attending Plrysician Refers to the physician selected by you or obtained by the Facility if your physician is unavailable. .Basic Services Refers to those services provided by the Facility that are included in the per diem rate. Responsible Party Refers to a person who is entitled to enforce all rights pertaining to residency on behalf of the resident and who is obligated to carry out the resident's responsibilities under this Agreement, except that the Responsible Party is not obligated to make payment for charges from the Responsible Party's personal funds unless the Responsible Party voluntarily agrees to accept financial responsibility for the Resident's obligations. Facility may give to the Responsible Party notices or information that would otherwise be given to the Resident. Facill Refers to Claremont Nursing and'Rehabilitation Center. 1 Per Diem Rate Refers to, in the case of a private pay resident, the daily rate charged by the Facility for basic services. For those resident's whose care is paid for by Medicare,Medical Assistance or other government or insurance program,the per diem rate is the daily reimbursement rate established by that government or insurance program. Schedule of Fees Refers to the fees charged by the Facility for those services provided by the Facility. The schedule lists the per diem rate for private pay residents and the fees associated with additional, supplemental services that the Facility provides that are not included in the per diem rate. Supplemental Services Refers to those services which are available to you,but are not included in the basic services covered by the daily per diem rate. These supplemental services are billed separately, in addition to the per diem rate. You or Your Refers to the resident who will receive the services provided by the Facility and for whom this Agreement is executed. Cfaremont Nursing andTska6iCitation Center A service agency forCum6erlandCounty 2 ARTICLE Z Obligations of Facility Nursing Services This Facility provides routine nursing care at a daily per diem rate described in the attached Schedule of Fees. Accommodations include both private and semi-private rooms,three meals each day, except as otherwise medically indicated,blankets, bed linens,towels and washcloths, laundering of linens and towels,housekeeping services, activity programs, and social services as established by the Facility. This Facility has a separate and distinct unit that provides care for Alzheimer Dementia residents who exhibit special needs consistent with a dementia diagnosis. Admission and discharge criteria for this unit are based upon the resident's nursing care needs throughout his/her stay at the Facility. Each resident residing on this unit will have their care needs reviewed periodically. When a resident who resides on this unit no longer meets the criteria for care on this unit, the interdisciplinary team will facilitate transfer of the resident to another area within the Facility. The Facility shall provide notice to the resident and/or responsible party of its intention to move the resident to another care unit. NondiscrinninatoLT Policv In accordance with Title VI of the Civil Rights Act of 1964,no resident shall be denied admission or appropriate care and placement following admission because of race, creed, color, national origin, ancestry, age, sex, handicap or disability. Basic Services Facility will provide the following services for you: • Routine care, including routine nursing care, specifically excluding private duty nurses or sitters; • Routine equipment and supplies; • Room and board; and • Social services and activities. CCaremont Nursing andiRs(ia6iCtation Center A service agency for Cum6erfand County 3 The basic services will satisfy the minimum requirements of federal and state law. Upon admission you shall be given an itemized list of charges for basic services and services available to you. This list of charges will be discussed with you prior to or at the time of admission. Supplemental Services In addition to Basic Services,the Facility provides services included on the Schedule of Fees under the heading Supplemental Services. Any items ordered by a physician,which are not part of the basic services,will be billed at charges identified by the Facility. Supplemental services are not included in the Facility's per diem rate and will be billed to you or the agency responsible for payment, These charges will be billed based on the resident's payor type and insurance. Supplemental services provided to the resident and not covered by any existing insurance will be billed in addition to the daily per diem rate. Notification of Chan-es Upon admission, you shall be given an itemized list of charges for routine service and to as much extent as possible, all applicable ancillary charges. The particulars of Third Party Payment (Medicare,Medical Assistance,Blue Cross, etc) where applicable, will also be explained in detail. Special Orders The Facility must have specific written orders to provide you with any medicines, treatments, or special diets from your Attending Physician or other medical and dental care providers. Equipment The Facility will provide the equipment necessary to deliver the Basic Services and any additional equipment ordered for.you by your attending physician. You and/or your government payer are responsible for the cost of additional equipment. Room Transfers Within Facili& The Facility reserves the right to change your room or roommate upon reasonable notice to you, subject to the provisions relating to transfers within the Facility contained in the Description of Resident's Rights which is attached to and a part of this Agreement. Claremont.Nursing and�Ryfiabih`tation Center A service agency for Cum6erC4nd County 4 Transfer and DischaM From Facility Facility may transfer or discharge you if at least one of the following occurs: • The Facility cannot meet your needs; • Your health has improved so that you no longer need the services provided by the Facility; • The safety or health of other individuals at the Facility would be endangered; • You have failed to pay, after reasonable and appropriate notice, for your stay at the Facility; or • The Facility ceases to operate. The Facility is required to give you thirty (30) days' written notice of transfer or discharge unless: • The safety or health of individuals at the Facility would be endangered by your continued stay in the Facility; • Your health has improved sufficiently to allow a more immediate discharge as determined by your attending physician; • An immediate discharge is necessary to meet your urgent medical needs as determined by your attending physician; or • You have resided at the Facility for less than thirty (30) days. In the case of an emergency, including those situations described above, only such notice as is reasonable under the circumstances shall be provided. The Facility will discharge you only upon the written order of the attending physician. If you specifically request discharge without a physician's written order, a written consent form must be signed. In the event you withdraw from the Facility, against the advice of your attending physician and without the approval of the Facility, all of the Facility's responsibilities for your care and treatment are immediately terminated. CCaremont Nursing and Reha6ifitation Center A service agency far Cum6er(4nd County 5 Transfer to HospitalBed Hold The Facility will transfer you to a Hospital when it is determined by your attending physician that there are medical reasons for doing so. Medical Assistance Eligible Residents If you are transferred to a Hospital and you are eligible for Medical Assistance at the time of transfer,the Facility will hold your bed for fifteen(15) days per spell of illness. You may request, in writing,that the Facility hold your bed longer than fifteen(I5)'days; however, you will be responsible for paying the Facility for any days beyond the fifteen (15) days at the same per diem rate that was reimbursed to the Facility by Medical Assistance prior to your transfer.to a Hospital. Private Pay and Medicare Eligible Residents If you are transferred to a Hospital and you are not Medical Assistance eligible, and you request, in writing,that the Facility hold your bed while you are in the Hospital,the Facility will charge you for each bed hold day at the same per diem rate that you or your government payer or private insurer were charged at the time of your transfer to the Hospital. If you elect not to reserve your bed, then you will be discharged from the Facility and readmission to the Facility shall be subject to bed availability. Please note that Medicare does not reimburse the Facility for bed holds. Next Available Bed If you choose not to reserve or hold your bed as otherwise permitted in this Agreement, you are entitled to the next available bed when you are able to return to the Facility, assuming,that the Facility can provide the services you require based upon the level of care you require at that time. Please initial that you have read this page. CCaremont u:rsing andlZf ha 6ilitation Center A service agency,for Cum6er4ind County 6 Therapeutic Leave The Facility will permit you to take a therapeutic leave away from the Facility when your attending physician orders it and includes in your plan of care. The Facility will hold your bed as set forth below: Medical Assistance Eligible Residents If you leave the Facility for therapeutic leave and you are eligible for Medical Assistance at the time you leave,the Facility will hold your bed up to thirty (30)day per year. The Facility will accept Medical Assistance bed hold payments as payment in full for the above-specified days. Non-Medical Assistance Eligible Residents If you leave the Facility for therapeutic leave and you are not eligible for Medical Assistance, you may request, in writing, that the Facility,hold your bed. You will be responsible for paying the per diem rate in effect for the days you are on therapeutic leave. Not An Insurer The Facility shall comply with its obligations under this Agreement and applicable state and federal laws and regulations. The Facility is not responsible for personal injury to you or your guests or loss or damage to your personal property except for personal injury, loss, or damage that results from the negligence or recklessness of the Facility. While you are on leave from the Facility, the Facility shall not be liable or responsible for any expenses, debts,or obligations incurred by you and shall not be obligated to furnish or provide for any support,maintenance, board or lodging. Consent To Substitute Physician The Facility shall attempt to obtain the services of your attending physician,when needed. If your attending physician is unavailable,you authorize the Facility to obtain the services of another physician selected by the Facility. You consent to treatment provided by another physician,when deemed necessary by the Facility, and in the absence of your attending physician. Claremont Nursing and lfkabilitation Center A service agency for Cumberland County 7 Disposition of Resident's Property Upon Death Iii the event of your death,the Facility shall use ordinary care in safeguarding your personal property that is retained on the premises. The Facility may immediately remove personal property from your room and store the personal property in a storage area. Property will be stored for up to fifteen (15) days. You are responsible for designating, in writing,a person who will make arrangements for the final disposal of all furniture and possessions and for the conduct and payment of expenses of any funeral or burial. Your Designate: 04-da�q Phone: ( ) &A, Address: Apt. City State Zip You may change the designated person at any time during your stay by noting the Facility in writing. Resuscitation Policy It is the policy of the Facility to resuscitate all residents without observable signs of life unless they have a Do Not Resuscitate physician's order. You will be provided an opportunity to provide advanced directive to your nursing and medical team on admission. Your attending physician will be consulted for appropriate orders. Reasonable Access The Facility must provide reasonable access to you by an entity or individual that provides health, social, legal, or other services to residents, subject to your right to deny or withdraw consent at any time. You have a right to receive information from agencies acting as client advocates and be afforded the opportunity to contact these agencies. CCaremont Nursing and Rsha&lztation Center A service agency forCum6erfandCounty 8 ARTICLE 3 Resident Rights The Facility has provided you with a Description of Resident's Rights as required by federal and state regulations. These Resident Rights include: Choice of.Providers You have a right to freedom of choice of providers in accordance with applicable law and subject to the provider's compliance with all applicable laws and reasonable rules and regulations of the Facility. Attending Physician You have the right to select and communicate with medical and dental care providers. You may designate, in writing, a physician of your choosing. Your Designate: Phone: ( ) Address: Apt. City State Zip You may change your attending physician by notifying the Facility in writing. If you do not select an attending physician, in writing,then the Medical Director of the Facility, or a physician designated by the Medical Director, shall serve as your attending physician. You understand that the attending physician must be granted and maintain privileges to practice at the Facility. Your physician must also see you at regular intervals and document your medical and nursing care needs and medication and treatment orders in the medical chart. Should your attending physician fail to meet these requirements,you will be asked to change physicians. The Facility is not responsible for the payment of any physician charges. The Facility may request the attending physician provide a copy of your written medical history and perform a physical examination within 48 hours of your admission to the Facility. You consent to the release of the medical history and physical examination report to the Facility. Claremont Nursing and q?§lua6iCtation Center A service agency for Cumberland County 9 .Personal.Funds You have the right to hold and manage your personal funds alone or with another responsible person outside the Facility. The Facility shall not be responsible for any loss of personal funds held by you. You will be provided, at your request, a key for the bedside stand to store personal belongings of value. If you authorize the Facility to manage your personal funds,the Facility shall use reasonable care to hold and safeguard those funds and shall account to you for your personal funds on a quarterly basis. I ACCEPT OR I DECLINE a key for the bedside stand Visitors You have the right to visitors and shall be free to visit with others of your choosing including members of the clergy at any time, providing that another's privacy is not infringed upon. The Facility has no limitations on visiting hours. The front door may be locked for security reasons during specific times. During these hours, visitors may use a door bell for access to the Facility. You have the right to be allowed privacy for visits with family, friends, clergy, social workers, or for professional or business purposes. Immediate Access You have the right to immediate access to any of the following, at your request: • Any representative of the Secretary of the United States Department of Health and Human Services; Medicare Service Center 1.800.633.4227 TDD 1.877.486.2048 • Any representative of the State; Governor's Action Line 1.800.932.0784 TDD 1.800.342.8040 • The state long term care ombudsman Cumberland County Area Agency on Aging Human Services Building 16 West High Street, Ste. 100 Carlisle, PA 17013 717.240.6110 or 1.877.697.0371 ext. 6110 Cfaremont Xursing andl?ghrabilitation Center A service agency for Cum6erfand County 10 • The agency responsible for the protection and advocacy system for mentally ill or developmentally disabled individuals; and/or PA Protection and Advocacy 1414 N. Cameron Street, Ste. C Harrisburg, PA 17013 1.800.692.7443 TDD 1.877.375.7139 • The Department of Health Harrisburg Field Office 132 Kline Plaza, Ste.B Harrisburg, PA I7104 717.783.3790 1.800.254.5164 • Your individual physician; • The immediate family or relatives of you or others who are visiting,with your consent. This right is subject to your right to deny or withdraw consent at any time. Communication You have the right to effective communication. Facility Services You have the right to perform or to refuse to perform services for the Facility that are not included for therapeutic purposes in your plan of care. You have a right to agree to perform voluntary or paid services for the Facility if you desire and there is no medical reason that would contradict the performing of services. Compensation for paid services will be provided at or above prevailing rates. Abuse You have the right to be free from mental and physical abuse, sexual and verbal abuse, or neglect, corporal punishment and involuntary seclusion. Claremont Nursing andWsha6ditation Center A seance agencyforCum6erfandCounty 11 Restraints You have the right to be free from chemical and physical restraints, except as authorized in writing by a physician for a specified and limited period of time,or when necessary to protect the resident'from injury to'him'self or others: Personal Freedom and Dien`ty You have the right to personal freedom and to be treated with consideration,respect, and full recognition of your dignity;and.individitality, including:privacy.intreatmerit,and in care for your personal needs that:contribute to,a.positive.self4mage:-"You have a right to-reason able accommodation of individual needs.and preferences except where the health or safety of you or other residents would be endangered. . Activities You have.the.right to participate in:social;• religious;-and conununity.activities.of your choosing and at your discretion unless medically contraindicated'and provided they,do not interfere with the rights of other residents. Transportation _ You have the right to access transportation to leave the building at your discretion for personal business as appropriate according to your plan of care. Privac)' k You have-the right to regular access to the private use of a telephone. You have the right if y married,to be assured privacy for visits by your spouse and if mutually,agreed upon to share a room,unless medically contraindicated. SeeuELtE You have a right to privacy and.security_. Quality ofLife You'hi ve a right to a'quality of life that supports independent expression, choice, and decision making;consistent with applicable law and regulation Cfaremont.Nursing and2 &a6il tdt o'n Center A service agency for cum6erfand County 12 Handling Of Personal Mail You have the right to receive and send personal mail unopened,unless medically contraindicated and so documented in your record. Facility staff are available and able to assist you in opening and reading any personal mail you may receive. You CONSENT DO NOT CONSENT that the Facility staff and/or volunteers may OPEN and/or READ your mail for you and/or to you. If a monetary gift is found upon opening your mail,you will be informed and asked permission to place it in your resident trust account or given to your Responsible Party for proper safekeeping. Business Mail is addressed in a separate form. Barber/Beauty Services You have the right to select your barber/beauty services. You CONSENT DO NOT CONSENT to authorize the Facility's in- house beautician to provide services. A uthorization To Review And Release Information You have the right to be assured confidential treatment of your personal and medical records and to approve or refuse their release to any individual outside the Facility, except in the case of your transfer to another health Facility, or as required by law or third party payment contract. You authorize all nursing facilities,hospitals, doctors and other health care providers to release to the Facility all requested information from your medical or financial records. You authorize the Facility to release medical or financial records, as requested and needed, to all hospitals, nursing facilities, doctors, and other health care providers involved in the management of your care. The facility will release your medical or financial records to third party payors of health care services and any insurance program you may be enrolled in,or to others deemed reasonably necessary by the Facility for the purposes of treatment,payment, and operations. CCaremont Nursing and 2i�p&a6iC:tation Center A service agency for Cum6erfand County 14 Authorized agents, such as the US Department of Health and Human Services, Centers for Medicare and Medicaid Services(CMS), the Facility's fiscal intermediary,the Pennsylvania Department of Public Welfare, and representatives from surveying institutions,may obtain resident records without written consent or authorization from you. You have the right to refuse to speak with persons not associated with this Facility or not directly involved in your care. You have the right to inspect all records pertaining to you upon verbal or written request within 24 hours of the request(excluding weekends and holidays). You have the right to purchase photocopies of your records or any portion of them upon written request with two (2)working days (excluding weekends and holiday)notice to the Facility. The cost of purchasing the records will be equivalent to the current prevailing rates. Self-Administration of Medications You have the right to self-administer drugs unless the Facility interdisciplinary team, including your physician,has determined that this practice is unsafe for you. Survey Results You have a right to examine the results of the most recent survey of the Facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the Facility. Claremont Nursing and�Rska& tation Center A service agency for Cumberland County 15 ARTICLE 4 Resident Responsibilities Cloth injz and Personal Belongaings You are responsible for providing your own clothing. You may bring personal belongings to the Facility,as space and safety permits, and to the extent that they do not infringe upon the rights of other residents and are not medically contraindicated as documented by your Attending, Physician in your medical record. You must notify the nursing staff when you bring personal belongings to the Facility so they may be inventoried and recorded. The Facility does not recommend that you bring items of unusual value to the Facility. All clothing items should be delivered to the nurse's station for labeling. The in-house seamstress will label all clothing. The Facility shall not be responsible for loss of or damage to your personal belongings. You may choose to have your personal clothing laundered by Facility staff at no additional cost to you. You CONSENT /\ DO NOT CONSENT that the Facility may launder your personal clothing. Cable Television Cable Television is available to you at the cost on the Rate Schedule. You CONSENT DO NOT CONSENT for cable television. Pets There are times when you may encounter cats or dogs. We feel that these animals are therapeutic and an enjoyable addition to our atmosphere. If you have an allergy to animals, please let the social worker know. Every effort will be made to prevent the animal from entering the rooms of allergic residents. You ARE ALLERGIC -DO NOT WANT CONTACT WITH ANIMALS ARE OK Personal Injury And Property Damaze You agree to pay for any damage that you or a guest cause to the Facility's property. Ordinary wear and tear is not considered damage. You shall be liable for any injuries to other persons caused by you or your guests,and you agree to reimburse the Facility for any sums paid or any costs incurred by the Facility,including attorney's fees. Claremont Nursing and q?fha6iCitation Center A service agency forCumbed4ndCounty 16 Authorization To Provide Treatment You authorize the Facility to provide,perform and administer the items and services included in the Basic Services. You authorize the Facility to provide,perform, and administer any Supplemental Services that you select. In addition,you consent to any routine medical care, tests and procedures rendered to you under the general or special instruction of your Attending Physician, subject to any advance directive, living will or other such document validly executed by you and provided to the Facility. Photozraph Release You CONSENT DO NOT CONSENT that all photographs,videotape, or film footage taken of you as well as recordings of your voice may be used by the Facility for the purpose of treatment, as well as publication, illustration, or advertising. Sa et You and your family are responsible to follow the Facility's policy relating to fire prevention, resident care, and general operational policies as stated but not limited to the provisions of the admission. You agree that in requesting personal electric equipment in your room, it is done at your own risk and you release the Facility from any and all responsibility for burns, injuries or property damage which may result from or because of said use of such appliances. You also agree to follow the Facility's smoking policies. You understand that infractions of the Facility's safety program,which place you or other residents at risk for harm, may result in your transfer or discharge from the Facility. Respect For Other Residents You and your family are responsible for respect and consideration for fellow residents including: • Being considerate of the rights of other residents and organization personnel; • Helping to control noise and disturbances; • Following smoking policies; and • Respecting the organization's and others' property. Claremont Nursing andWsha6ditation Center A service agency for Cumberland County 17 Providing Information You and your family are responsible for providing accurate and complete information,to the best of your knowledge about: • Present complaints; • Past illnesses; • Hospitalizations; • Medications; and • Other matters relating to your health. You and your family are also responsible for: • Reporting to the responsible practitioner unexpected changes in your condition; and • Indicating whether you clearly understand a proposed course of action and what is expected of you. Follorvinz Instructions You and your family are responsible for following the treatment plan developed with the practitioner. You are responsible for expressing any concerns about your understanding of the course of treatment and ability to comply with the proposed course. Every effort is made to adapt the plan to your specific needs and limitations. When such adaptation to the treatment plan is not clinically indicated,you are responsible for understanding the consequences of the treatment alternatives and of not following the proposed course Refusinz Treatment You and your family are responsible for the outcomes if you do not follow the plan of care. Financial Commitments You and your family are responsible for promptly meeting any financial obligation agreed to with the organization. The resident's family or surrogate decision maker assumes the above responsibilities for the resident if the resident: • Has been found by his or her physician to be medically incapable of understanding these responsibilities; Claremont Nursing and gZ FWihitation Center A service agency for Cum6erland'County 18 • Has been judged incompetent in accordance with law; and/or • Exhibits a communication barrier. Competence If this agreement is signed by you and not your Responsible Party, you acknowledge that you are being admitted to the Facility freely and according to your own will. You represent and covenant that you are competent,having never been declared incompetent and are not aware of any pending proceeding to determine your competence. Rules and Regulations You agree to abide by the Rules and Regulations of the Facility. The Rules and Regulations may change from time to time. The Facility will give you advance notice of any changes or new Rules and Regulations. You acknowledge receipt of the current Rules and Regulations. The Rules and Regulations, as they may be amended from time to time, are considered.part of this Agreement. Claremont Nursing and�Rs(ua&titation Center A service agency for Cumberland County 19 ARTICLE 5 Financial Azi-eement Schedule Of Fees A Schedule of Fees is distributed at the time of Admission. It includes the per diem rate for private pay residents and the charges for Supplemental Services that may be provided to you. The Facility may modify the Schedule of Fees from time to time. The Facility will provide you with reasonable advance notice of any changes to the Schedule of Fees. Oblations of Resident Resident is obligated to make full and complete disclosure regarding all financial resources and income during the application process. Failure to identify all resources and income, or the submission of false information,may result in termination of this Agreement. Resident is obligated to notify the Facility when the resident's resources available to fulfill financial obligations under this agreement have been reduced to Ten Thousand Dollars($10,000). Medical Assistance Admissions and Eligibility The resident is obligated to apply for Medical Assistance benefits at such time as the Resident's resources will no longer be sufficient to pay all Facility charges for resident's care and stay or when directed to do so by the Facility. The Facility will assist you in applying for Medical Assistance. You agree to cooperate fully,to the best of your ability,with such application. The Facility may not require a promise from you or your Responsible Party to apply as a condition of admission to the Facility or otherwise. However, if you become eligible for Medical Assistance, you are not relieved from your responsibility to pay the per diem rate and other applicable fees for any days or services that are not covered by Medical Assistance. In the event resident applies for Medical Assistance benefits,the resident shall continue to pay and apply all of the resident's available resources toward fulfillment of the resident's financial obligations under this agreement while the Medical Assistance application is pending and eligibility for benefits is determined by The Department of Public Welfare (DPW). You are responsible to pay to the Facility the patient pay amount of the Medical Assistance per diem. Claremont Nursing and Pfha6ditation Center A service agency for Cum6er(and County 20 Patient Pay Amount For residents approved for Medical Assistance benefits,the Facility will accept payment from the Commonwealth of Pennsylvania and,if applicable,the resident's patient pay amount as determined by the Department of Public Welfare,as payment in full only for those services covered by the Medical Assistance program. The resident remains obligated to pay the determined Patient Pay amount, less any qualified medical expense deductions, on a monthly basis. Services not covered by Medical Assistance are identified in the rate schedule and the resident remains obligated to pay for such services. In the event the resident qualifies for Medical Assistance benefits, the resident or responsible party,to the extent permitted by law, shall arrange for assignment to the Facility of any payment on behalf of the resident in an amount equivalent to the Patient Pay amount as determined by the Department of Public Welfare. Government Payor Resident Charges This paragraph applies once you are eligible for reimbursement of your nursing home services by Medical Assistance, Medicare, or other government payment program. The Schedule of Fees sets forth those items and services that are covered by the respective government program. You will not be billed separately for these charges. You are responsible for paying all charges assessed by the Facility for services not covered by the government payment program, according to the Schedule of Fees in effect at the time services or products are provided. A copy of the current Schedule of Fees is attached to and made part of this Agreement. Private Resident Chames You are responsible for paying all charges assessed by the Facility, according to the Schedule of Fees in effect at the time services or products are provided. The Facility will assist you in applying for and obtaining additional benefits, in which you may be eligible,to cover the cost of your care at the Facility. Billing And Collections You will be billed monthly, in advance, for all services and products provided to you for which you are financially responsible. Amounts are due on the first of the month.. Any amount not paid within thirty (30)days of the billing is considered overdue. A finance charge,not to exceed Claremont Nursing and�R§fia&litation Center A service agency for Cumberland County 21 1.5%per month of the overdue balance,may be charged. You will be responsible for paying any costs incurred by the Facility in collecting unpaid charges, including reasonable attorney's fees. Your Personal Funds—Guest.Fund You are responsible to provide your personal funds and you have the right to manage your personal funds. You may authorize the Facility, in writing, to hold your personal funds in the Guest Fund account. The Facility will hold, safeguard, and account for your personal funds in accordance with regulatory requirements. You ,L` DO AUTHORIZE DO NOT AUTHORIZE the Facility to accept and maintain all of your personal funds in accordance with federal and state regulations and any other applicable law or regulation. You may change this authorization at any time with written notice to the Facility. The obligations of the Facility to manage and maintain your personal funds are limited to the requirements of applicable law and regulations. Refunds of Personal Funds Any personal funds or valuables held by the Facility will be refunded, subject to deductions for payment of any outstanding bills or other amounts due to the Facility, such as any costs incurred by the Facility to repair resident room damages, within thirty(30)days after the resident's discharge or death. In the event of the resident's death, refunds will be made to the duly authorized representative of the estate or to such entities or persons entitled to the refund under current law. No interest shall accrue on any refunds required to be refunded under this Agreement. Claremont Nursing andWSkadititation Center A service agency for Cumberfund County 22 ARTICLE 6 Miscellaneous Provisions Termination In the event of termination of this Agreement for any reason,you shall be responsible.for charges equal.to the portion of the monthly charges corresponding to the number of days you stayed at the Facility in the month of termination. Termination By Resident This Agreement can be terminated upon reasonable notice by you to the Facility. Termination By Facility This Agreement may be terminated by the Facility and you may be discharged in accordance with the transfer and discharge provisions described in this Agreement and the description of Resident's Rights attached to this agreement. Entire Agreement This Agreement, the Application for Admission, the Schedule of Fees,the Description of Resident Rights, and any other exhibits that are attached to this Agreement, together constitute the entire agreement between the parties. There are no other agreements, oral or written, regarding your care at the Facility. Captions Paragraph captions are for convenience only and are not part of the Agreement. Severability Each provision of this Agreement is separate. If one provision is determined to be invalid,the rest of the Agreement shall continue in full force and effect. It is the intent of the parties that if any provision of this Agreement is determined to be unenforceable as written,then the provision shall be enforced to the extent permissible by law. Claremont Nursing and q4hadilitation Center A service agency for Cumberland County 23 Notices Any notices contemplated by this Agreement to be given by you to the Facility should be directed to Your Designate: Phone: ( ) Address: Apt. City State Zip Any notice required by this Agreement to be given to you shall be delivered to you at the Facility. Notice is considered to have been given when the notice is delivered. Applicable Law This Agreement shall be construed in accordance with state law. No Assignment You may not assign your rights under this Agreement. Any attempted assignment will render the Agreement void. Modification The Facility may modify this Agreement from time to time. The Facility will provide you with advanced written notice of any modification. Claremont Nursing and'Ts6abilitation Center A service agency forCum6edandCounty 24 ADMISSION AND FINANCIAL AGREEMENT SIGNATURE RECORD The Parties, intending to be legally bound, execute this Agreement on the date first noted below. Payment of Third Party Benefits is authorized to the Facility on the resident's behalf for any services furnished by the Facility. The responsible party is obligated to make resident's financial resources available to Facility in accordance with Article 5 of this Agreement and failure to do so could result in Iiability for the misappropriation of the resident's funds and assets. Your signature reflects that you have been informed both orally and in writing of your rights and all rules and regulations governing resident conduct and responsibilities during your stay in this Facility as defined in this Admission and Financial Agreement. You also acknowledge that the Facility provided you with a resident handbook and a statement describing the current state law regarding advance directives and your rights regarding advance directives and that the statement has been explained to you. You also acknowledge that the Facility provided you with a copy of the Privacy Act Statement— Health Care Records and Your rights regarding this act have been explained to you. Witness To Resident's Signature: For Resident: JCL : . (Name and Title) (Resident's Signature) (Date) -OR-. For the Facility: {Fac pfyVePres nta 've Signature) (Responsible Party's Signature) (Date) (Date) Claremont 9lrursing andMa6ditation Center A service agency for Cum6erland County 25 This full agreement as explained orally and distributed in writing to the resident may be found in the resident's business office file. Revised---January 2009 Claremont Nursing and&haftfitation Center ,A service agency forCum6erlandCounty 26 NeiSoludous icons NTI'DATA Page 1 of 1 FC09 - CLAREMQNT NURSING & REHAB CTR NTT IyATA _'y :�. -w r�.� _� -- - �- < _Fri Sep 20 2013,04:27:21 p.m. nn r ! :. :- 'Crystal Brallier � U Financial Snapshot HAVERSTOCK, PATRICIA A �`HR# 5491 ACCT# 623 ( IP VISIT FOR 08/23/2011 i _ _ _ _ COMMON TASKS °i URRENT LOCATION- CNC22062 '� aor�rssloN DISCHARGE TYPE ACCOUNT# HR Select Resident ;< EA RECORD#: 08/23(2011 09/23/2011 IP 623 5491 =� ocoulur#: {23 09/29/2010 10115/2010 IP 623 5491 12 Select Facility ® E-mail �- ATE OF BIRTH: ENDER: Female 9 help i 7 -0 Slgn Out '.:'View basic information eDocs View visit information New visit KNS CONNECTIONS Insight Dashboard VISIT INFORMATION FOR ADMISSION: 08/23/2011 Care Tracker r•CENSUS INFORMATION :;m eDocuments FROM DATE THRU DATE LOCATION BED TYPE STATUS LEVEL OF CARE HOLD TYPE 8U/PL z ADT 08/2312011 09123/2011 CNC22062 Two/East —{ Snapshot ' Q, Registration ransfer Hold Reserve Swap W REIMBURSEMENT INroRMATION T Discharge :;! PLAN TYPE START DATE END OATE RATE DAYS USED AS OF c Care Level _ MEDICARE B Medicare 08/2312011 8/31/2013 Location Status s FEDERAL BLUE CROSS PART B COINSURANCE Commercial 08/23/2011 8131/2013 Cancel Admit ';� MA PENDING Medicaid 08/23/2011 0.00 8/31/2013 Cancel Outpatient PRIVATE PAY Guarantor 08/2312011 0.00 8/31/2013 Central Res. Index CHARTING $ ACCOUNTS :• v' ACCOUNT PAYOR/PLAN BALANCES as of 8/31/2013 Snapshot :; PLAN PAYOR BALANCE RECEIPTS ADJUSTMENTS OUTSTANDINe Charge orders), MEDICARE B Medicare B 0.00 0.00 0`00 0.00 Receipts> FEDERAL BLUE CROSS PART B COINSURANCE Federal Blue Cross 0.00 0.00 0.00 0.00 Assessments), MA PENDING MA - Medicaid Pending 0.00 0.00 0.00 0.00 Status 4 PRIVATE PAY HAVERSTOCK, PATRICIA 8253.00 0.00 0.00 8253.00 ,o Credits), FEDERAL BLUE CROSS PART A COINSURANCE Federal Blue Cross 0.00 0.00 0.00 0.00 Co BILLING w RESIDENT FUNDS .n Charges> Reset Account FUND PERIOD BEG BALANCE DEPOSITS WITHDRAWALS BALANCE _ Clear Error Log Trust Fund 9130/2012 0.00 D.00 100 0.00 N Bills P W AIR Ar•tiyitiac rr v >' http://nhnhsr02/NetSolutions/ADT/adt.htm?sto=true 912012013 Sep- 20. 2013 . 4: 19PM CLAREMONT BUSINESS OFFICE No. 1899 P. 3/3 ;I TT DA1A neiamutions rage I of 1 Y SALANCE INFORMATION PERIOD BALANCE 9/1/2011 5958.00 8/1/2011 2295.00 d 1,rr,; //nf,.,A�rt17lNRtCnI„t;r,,,�/RAM/FinCnanRalT)etail.acnx?accn�mtf nde=�i23&navorCode-107&tilanCa... 9/20/2013 SHERIFF'S OFFICE OF CUMBERLAND COUNTY Ronny R Anderson Sheriff .. T H r PRO T H O N!o TA ij r�NNtr t"iriti p� rx,. Jody S Smith Chief Deputy OCT »3 PM 2: 4 „� Richard W Stewart CUM EPLA D COUNTY Solicitor QMG O 'HE 11ERIFP PENNSYLVANIA Claremont Nursing and Rehabilitation Center VS. Case Number Patricia Haverstock 2013-5142 SHERIFF'S RETURN OF SERVICE 09127/2013 04:06 PM-Deputy Jamie DiMartle, being duly sworn according to law, served the requested Complaint& Notice by handing a true copy to a person representing themselves to be Jennifer Concannon, granddaughter,who accepted as"Adult Person in Charge"for Patricia Haverstock at 2307 New York Avenue, Lower Allen, Carlisle, PA 17011 ,. J IE DIMART PUTY SHERIFF COST: $35,24 SO ANSWERS, September 30, 2013 RONW R ANDERSON, SHERIFF {c}CountySultt Sheriff,Teteosoft,Inc, ILA `6V1' . .12 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CLAREMONT NURSING AND REHABILITATION CENTER, Plaintiff, v. PATRICIA HAVERSTOCK, Defendant. CIVIL ACTION No. 13-5142 PRAECIPE FOR JUDGMENT TO THE PROTHONOTARY: Please enter judgment in favor of Plaintiff and against Defendant, Patricia Haverstock, for want of an answer. X Assess damages as follows: Debt $ 8,253.00 Interest from 10/31/2011 @1.5% per month $ 3,713.85 Attorney's Fees and Costs $ 3,535.43 TOTAL $ 15,502.28 X I verify that the foregoing assessment of damages is for specified amounts alleged to be due and is calculable as a sum certain. X Pursuant to Pa.R.C. 237 (notice of praecipe for final judgment or decree), I certify that a copy of this Praecipe has been mailed to each party who has appeared in the action or to her Attorney of Record. 399704v1 1 4,1 tp, 10--� 3a>o��PSG Wee( Q26�7? a X Pursuant to Pa.R.C.P. 237.1, I certify that written notice of the intent to file this Praecipe was mailed or delivered to the party against whom judgment is to be entered and to her Attorney of Record, if any, after default occurred and at least ten (10) days prior to the date of the filing of this Praecipe and a copy of the Notice was sent to the Defendant via Certified Mail, Return Receipt Requested and via First Class Mail, postage prepaid. The Certified Mail was returned marked "Unclaimed". However, the envelope forwarded via First Class Mail has not been returned to our office. Dated: a0/ By: LATSHA DAVIS & MCKENNA, P.C. Steven M. Montresor Attorney I. D. No. 74244 1700 Bent Creek Blvd., Suite 140 Mechanicsburg, PA 17050 (717) 620-2424 smontresor@ldylaw.com Attorneys for Plaintiff, Claremont Nursing and Rehabilitation Center NOW, Oil 1 Ia , 20 1l , JUDGMENT IS ENTERED AS ABOVE. By: 399704v1 2 Renee K. Simpson 1st DeputlQf Pr !`*b G../'C Civi vision, 1st Deputy i Steven M. Montresor Attorney ID #74244 Latsha Davis & McKenna, P.C. 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 Tele: (717) 620-2424; Fax: (717) 620-2444 smontresor@ldylaw.com Attorneys for Plaintiff, Claremont Nursing and Rehabilitation Center IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA CLAREMONT NURSING AND REHABILITATION CENTER, Plaintiff, PATRICIA HAVERSTOCK, Defendant. CIVIL ACTION No. 13-5142 DATE OF NOTICE: March 6, 2014 IMPORTANT NOTICE TO: Patricia Haverstock 2307 New York Avenue Camp Hill, PA 17011 YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST YOU. UNLESS YOU ACT WITHIN TEN (10) DAYS FROM THE DATE OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER 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. 386658v1 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. 386658v1 Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 1-800-990-9108 (717) 249-3166 2 Steven M. Montresor CERTIFICATE OF SERVICE The undersigned hereby certifies that on this date a true and correct copy of the foregoing Notice of Default Judgment was served by certified, return receipt, and first-class United States mail, postage prepaid, upon the following: Dated: .7'6 ?(-)11 386658v1 Patricia Haverstock 2307 New York Avenue Camp Hill, PA 17011 3 Steven M. Montresor