HomeMy WebLinkAbout14-5694 Supreme Cog T Pennsylvania
COUP of.Comoro v leas For Prothonotaoi Use Only:
CI itubver'Sheet
Docket No: ^ j,
CUMBLAND County \H,
S W
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 El Complaint 0 Writ of Summons 1ll Petition
0 Transfer from Another Jurisdiction 3 Declaration of Taking
E
C Lead Plaintiffs Name: Lead Defendant's Name:
T Church of God Home, Inc. Vernadeen E. Junkins, Michael E. Junkins and Barry L.�
�
Dollar Amount Requested: D within arbitration limits
I Are money damages requested? El Yes 0 No (check one) xi outside arbitration limits
O
N Is this a Class Action Suit? 0 Yes r No Is this an MDJAppeal? Yes � No
A Name of Plaintiff/Appellant's Attorney: Brian K. Zellner, Esquire
0 Check here if you have no attorney(are a Self-Represented [Pro Sel 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 EI Buyer Plaintiff Administrative Agencies
Malicious Prosecution ❑ Debt Collection: Credit Card 0 Board of Assessment
Motor Vehicle El -Debt Collection: Other 0 Board of Elections
hI Nuisance E Dept.of Transportation
0 Premises Liability Statutory Appeal: Other
S h; Product Liability (does not include
E mass tort) 0 Employment Dispute:
Slander/Libel/Defamation Discrimination
C 1 Other: ❑ Employment Dispute: Other Zoning Board
T ❑ Other:
I 0 Other:
. o MASS TORT
El Asbestos
N [3 Tobacco
Toxic Tort-DES
0 Toxic Tort-Implant REAL PROPERTY MISCELLANEOUS
0 Toxic Waste 0 Ejectment 0 Common Law/Statutory Arbitration
B 0 Other:
Eminent Domain/Condemnation rl Declaratory Judgment
El Ground Rent 0 Mandamus
1=! Landlord/Tenant Dispute 0 Non-Domestic Relations
LMortgage Foreclosure: Residential _ Restraining Order
PROFESSIONAL LIABLITY 3 1-�Mortgage Foreclosure:Commercial Quo Warranto
0 Dental 0 Partition 0 Replevin
11 Legal 0 Quiet Title 0 Other:
0 Medical ❑ Other:
i3 Other Professional:
Updated 1/1/2011
Brian K. Zellner, Esquire t T U il" 1CF
N 1�h,i,
Hynum Lawt , SEP
Supreme Court ID #59262 �6
2608 North 3rd Street UE F?[ ,
Harrisburg, PA 17110 PEN4S Y ANIA Y
(717) 774-1357
CHURCH OF GOD HOME, INC., IN THE COURT OF COMMON PLE S
Plaintiff CUMBERLAND COUNTY, PA
NO. . SLP 'I 3u t
v.
VERNADEEN E. JUNKINS,
MICHAEL E. JUNKINS and
BARRY L. JUNKINS
Defendants : 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
2 Liberty Avenue
Carlisle, PA 17013
(717) 249-3166
(800) 990-9108
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C.� 87av
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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 1NFORMACION 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
2 Liberty Avenue
Carlisle, PA 17013
(717) 249-3166
(800) 990-9108
Brian K. Zellner, Esquire
Hynum Law
Supreme Court ID #59262
2608 North 3rd Street
Harrisburg, PA 17110
(717) 774-1357
CHURCH OF GOD HOME, INC., IN THE COURT OF COMMON PLEAS
Plaintiff CUMBERLAND COUNTY, PA
NO.
V.
VERNADEEN E. JUNKINS,
MICHAEL E. JUNKINS, and
BARRY L. JUNKINS
Defendants : CIVIL ACTION—LAW
COMPLAINT
1. Plaintiff Church of God Home, Inc. is anon-profit continuing care community located at 801
N. Hanover Street, Carlisle, PA 17013.
2. Defendant Vernadeen E. Junkins is an individual who resides at 801 N. Hanover Street,
Carlisle, PA 17013.
3. The Defendant Vernadeen E. Junkins was admitted into the Plaintiff's facility in March 4,
2011.
4. The Defendant Vernadeen E. Junkins has been a resident of the Plaintiff since March 4,
2011.
5. The Plaintiff is owed $60,641.81 for care and services rendered to the Defendant
Vernadeen E. Junkins. Attached hereto as Exhibit A is a true and correct copy of the current
Statement.
COUNT I BREACH OF CONTRACT -- VERNADEEN E. JUNKINS
6. Paragraphs 1 through 5 are incorporated herein by reference as though set forth at length.
7. On March 4, 2011, Plaintiff and the Defendant Vernadeen E. Junkins entered into a
written agreement pursuant to which Plaintiff agreed to admit her into its facility, in
consideration for her agreement to pay for room, skilled nursing care and other services. See
attached hereto as Exhibit `B" is a true and correct copy of the Admission Agreement.
8. The Defendant Vernadeen E. Junkins is $60,641.81 in arrears on payments to Plaintiff.
9. Despite repeated demands by Plaintiff for payment, the Defendant Vernadeen E. Junkins
has failed and refused and continue to fail and refuse to pay this amount.
10. The failure to remit to Plaintiff the amount owed is a material breach of the agreement
between the parties.
11. The breach, as aforesaid, has caused Plaintiff injury in the amount of$60,641.81.
WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows:
a. Granting judgment for the Plaintiff and against the Defendant Vernadeen E. Junkins in the
amount of$60,641.81;
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 March 4, 2011; and,
d. Granting such other relief as the Court deems equitable and just.
COUNT I I -- DUTY TO SUPPORT—MICHAEL E. JUNKINS
AND BARRY L. JUNKINS
12. Paragraphs 1 through 11 are incorporated herein by reference as though set forth at
length.
13. As the nursing facility that provides Vernadeen E. Junkins with skilled nursing care and other
services,the Plaintiff has a legal duty to provide care, maintenance, and assistance to her.
14. 23 Pa.C.S. § 4601 et. seq. provides that relatives may be liable for the support of indigent
persons.
15. The Defendants Michael E. Junkins and Barry L. Junkins are the sons of Vernadeen E.
Junkins.
16. Upon information and belief, Defendants Michael E. Junkins and Barry L. Junkins are of
sufficient financial ability to care for and financially maintain and financially assist in the
payment of Vernadeen E. Junkins' care.
17. The expense of living in the Plaintiffs facility exceeds Vernadeen E. Junkins' income to the
extent that applied for and is receiving Medical Assistance.
18. Vernadeen E. Junkins is "indigent"within the meaning of the Support Act.
19. The Defendants Michael E. Junkins and Barry L. Junkins are obligated to reimburse Plaintiff
for the nursing care and services rendered to Vernadeen E. Junkins pursuant to the Support Act.
20. The Defendants Michael E. Junkins and Barry L. Junkins have not reimbursed the Plaintiff
for the nursing care and services rendered to Vernadeen E. Junkins.
21. The Plaintiff has been damaged by the violation of the Support Act by the Defendants
Michael E. Junkins and Barry L. Junkins.
WHEREFORE, Plaintiff respectfully requests this Honorable Court to enter an Order as follows:
a. Granting judgment for the Plaintiff and against the Defendants Michael E. Junkins and Barry
L. Junkins in the amount of$60,641.81;
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 March 4, 2011; and,
d. Granting such other relief as the Court deems equitable and just.
Date:
1
Brian K. Zellner
Attorney ID 59262
Hynum Law
2608 North 3rd Street
Harrisburg, PA 17110
[717] 774-1357
VTRIIUCATION
1, 4l\ 6ctic1 ,hereby state that I ani the authorized representative of the
Plaintiff in this action and that the statements of fact madeui 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,Aim 4904
relating to unsworn I'alsiiication to authorities.
Date, —� -
Panted Name; E�ya✓\ ����,.!
Title: C-t=J
/ e
10
CHURCH OF GOD HOME, INCti' `
801 N. HANOVER STREET Form PB-01
CARLISLE,PA 17013
RESIDENT# UNIT STMT. DATE
413 H120A 07/31/2014
— RESIDENT(S)
NEIGHBORHOOD SERVICES Vernadeen E.Junkins
134 &PRINCE STREET
PO BOX 1593 TOTAL AMOUNT DUE $60,641.81
LANCASTER,PA 17608-1593
DETACH AND RETURN THIS PORTION WITH YOUR REMITTANCE $
........_.....— — .
-.-............ ___ __......._.. ... ._ EMITTED..
DATE DESCRIPTION Units CHARGES CREDITS BALANCE
Balance Forward 52,441.82
07/10/2014 Payment on account 559.00 51,882.82
07/01/2014 Laundry 07/01-07/31 1 36.25 51,919.07
07/04/2014 Shampoo & set 1 13.30 51,932.37
SET
07/05/2014 Medical Supplies-Incontinence 1 12.51 51,944.88
Underwear, XL
07/06/2014 Medical Supplies-Incontinence 1 1.98 51,946.86
WET WIPES
07/09/2014 Medical Supplies-Incontinence 1 9.73 51,956.59
UNDERWEAR,PROTECTIVE, ULTRA,
07/11/2014 Shampoo & set 1 13.30 51,969.89
SET
07/11/2014 Medical Supplies-Incontinence 1 1.98 51,971.87
WET WIPES
07/18/2014 Shampoo & set 1 13.30 51,985.17
SET
07/20/2014 Medical Supplies-Incontinence 1 10.69 51,995.86
pullup, large
07/24/2014 Shampoo & set 1 13.30 52,009.16
SET
07/26/2014 Medical Supplies-Incontinence 1 1.98 52,011.14
WET WIPES
07/28/2014 Medical Supplies-Incontinence 1 10.69 52,021.83
pullup, large
07/29/2014 Medical Supplies-Incontinence 1 1.98 52,023.81
WET WIPES
08/01/2014 Nursing Care-Private Pay 08/01-08/31 31 8,618.00 60,641.81
Please call the billing office at 717-866-3256 or 717-866-3255 with any statement questions.
All checks should be made payable to Church of God Home. Please use the enclosed envelope
to mail your payment.
RESIDENT# CURRENT OVER 30 OVER 60 OVER 90 OVER 120 TOTAL AMOUNT DUE
413 8,758.99 8,822.58 17,182.15 8,552.74 17,325.35 $60,641.81
RESIDENT NAME Vernadeen E. Junkins Form PB-01
EXHIBIT
CHURCH
Of GOD
HOME
"Committed to Curing" t
1
f.
Nursing Care
Admissions Contract
Information
f
r j
1
1
I Church of God Home, Inc.
' 801 N. Hanover Street• Carlisle, PA 17013
P: (717) 249-5322 - F: (717) 249-8622 "
EXHIBIT �
Revised 1112009
i
CHURCH
OF GOD ,
NOME
"Committed to Carin4"
i
Dear Friend:
Admission into a health care facility is a learning experience,both for the new resident and their family. We j
at the Church of God Home try to make the admission process as positive, pleasant and easy as possible.
Because of the number of documents that must be explained and signed upon admission,many facilities
look at this as being"overwhelming However,both State and Federal regulations require such forms for
permanent records.
As we welcome the new resident,a hand is extended in friendship...an arm is offered for support...a
cheerful pat of encouragement is given...these are a few of the special touches that the Church of God
i Home has been offering since its doors first opened in 1948.
i
For more then sixty years a Christian spirit has been the guiding philosophy of our Home. That's the w
reason our care goes far beyond just meeting the physical needs of our residents.
i We believe in the dignity and self-worth of each individual, and every aspect of our care reflects that belief.
Our mission is to minister to-the physical,spiritual, and emotional need of each resident in order to help him
or her lead a more meaningful life.
In sharing these values and standards of the Church of God Home,we hope that our experience will benefit I
others so that,together,we will continue to find better ways to serve the needs of elderly people in our
society.
j Carson G. Ritchie,CPA, NHA
President/CEO
E
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2
Table of Contents
1 Welcome Letter.................................. ............ ..........................................................................2
2. Statement of Vision and Mission........................................................................... .....................4
3. Ambulance......................................................... ..............................................................--......4
4. Chart of Costs..............................................--.....................................................................-5-7
5, Dietary Services ......... ........ ...................................................... ............................... ...........7-8
6, DVD"A Time of Transition".......................................................................---............................8
7. Guest Room................... .................... .......... ......... ....... ...................... ..................................8
8. 'Lehigh Valley Respiratory Care—Lancaster..............................................................................9
9. Medicaid (Medical Assistance).............................................................................................9-10
10. Medicaid (Medical Assistance)Residents.............................-.................................................11
11. Medicaid (Medical Assistance)Residents Checklist........................................................... 12-13
12. Medicare....................................... ......................................... ........................................... 14-15
13. Mobile X-Ray Imaging, Inc..................................-....................................................................16
14. Psychiatrist..................... ....................................................................................................16
15. Smoke Free Environment.................. ......................................................................................17
16. Specialized Services............................ .......... ................... ...........................17
17, Transportation..........................................................................................................................17
18. Understanding Restraint Use.......................................................... .........................................18
19. Advance Directive Policy............................................ .............................................. ..............19
20. Complaint Procedure.............................................................. .................................................20
I.
21. Delegation of Responsibility Form............................................................................. ..............21
22. Legal Rights Compliance................................................ ............. ................. .........................22
23, Non-Discrimination Statement. ....................... ..................................................... .............23
24. Personal Cash Accounts I Depleted Funds... ........................................................ ...........24-25
25, Personal Laundry Service.........................................................................................................26
26. Pharmacy Services.................... ........... .......................................................--.................27-34
27. Podiatry Services.............................................................. ............................ ..........................35
28. Privacy Act Statement—Healthcare Records......................... ........................................—36-37
29. Private Room Policy/Nursing....................................................... ..........................................38
30. Therapy................................................................. ..................................................................39
31. Vaccinations...--................... ......... ....................................... ........................... ........40-45
32. Valuables...................;................1-1.1-1...... .......a............ ........................................ .........46
33. Admission and Care Agreement........................................ ................................................47-55
a. Security Deposit......................................................... ................................. .....................47
b. Readmission—Bed Hold Policy..........................................................................-.............49
34. Resident I Family Guide to Inquiries and Information.........................................................53-54
35. "Welcome"(Telephone/Extension)...........................................................................................55
31* Checklist.... .......*51
r- .
t
STATEMENT OF VISION AND MISSION
t
Vision
To provide an aging services'continuum of care that reflects the perfect love of Christ,exceeding the
expectations of those we serve.
i
Mission
i Church of God Home,a Continuing Care Retirement Community, is a Christian Ministry committed to caring for
the body, mind and spirit of older persons.
I
Admissions Policy
I
It is the policy of the Church of God Home, a unit of the Eastern Regional Conference of The Churches of God,to
admit and treat all persons without regard to race,color,national origin,age, ancestry,sex, handicap,disability or
religious creed.
i
Only those applicants whose medical nursing care,psychological and behavioral needs can be adequately met
by the staff,will be admitted or kept in this facility. In addition,all residents must meet the financial criteria of
private pay, Medicaid or SSI payer source.
The Board of Trustees is committed to providing housing,services and needed responsible care for older persons
i with priority to those who are members of,or affiliated with,the Eastern Regional Conference of The Churches of
God.
The same requirements for admission are applied to all, and residents are assigned within the facility without
regard to race,color,national origin,age,ancestry, sex, handicap,disability or religious creed. 1
There is no distinction in eligibility for,or in an manner of, providing an resident service that is provided b or
� g h+ Y p g Y P Y
through the facility.
All areas of the healthcare center are available to all persons and visitors regardless of their race,color, national r
! origin, age, ancestry,sex, handicap,disability or religious creed.
All persons applying for admission,or who are recommending individuals to the Church of God Home,are j
advised to do so without regard to the person's race,color, national origin,age, ancestry,sex,handicap, i
disability,or religious creed. I
I
Ambulance I
Ambulance enrollment is recommended but is not handled by the facility. If you desire enrollment, please contact ! c
them independently.
3
Chart of Costs Effective January 1, 2009
Nursing Care Room Rates
Faith Wing and Love Wing
Semi-Private $236.00 per day
Private $290.00 per day
Personal Care Room Rates
Hope Wing and Peace Wing ,
Semi-Private $103.00 per day(Rm401-411)
Private $111.00 per day(Rm301)$121.00 per day(Rm303-313)$129.00 per day(Rm400)
Creekside Apartments
Studio One Bedroom One Bedroom, Creek view
One person $145.00 per day $165.00 per day $170.00 per day
Two persons $245.00 per day $270.00 per day $315.00 per day
Note: There will be a security deposit charged based on a 31-day month at the per diem rate for
roomllevel of care. In the event of a Level of Care change to a higher level the residentiresponsible party
will be billed the difference between the security deposits. There are no additional charges while
receiving benefits under the Medicare program while in nursing care(except telephone,hair care,
personal laundry,transportation,bed hold,bed reserve and name labels),
f Independent Living Rates
LeTort Manor Apartments
Apartment Monthly Fee
One Person Two Persons
A $905 $1,215
B $835 $1,125
C $835 $1,125 '
D $820 $1,115
E $820 $1,115
Apartment Type 40%Refundable Rate Non-Refundable
Apartment W $109,000 $83,000
Apartment "B" $96.100 $73,000
Apartment °C° $96,100 $73,000
Apartment "D° $81,000 $63,000
i Apartment OF $81,000 $63,000
Independent Living Rates i
Creekside Apartments a
Apartment Monthly Fee
One person Two Persons
' Efficiency $1,305 $1,785
One Bedroom $1,650 $2,290
_I
Chart of Costs (continued)
Bed Hold(during hospitalization or LOA) Per Diem rate
I
Cable Television(Nursing and Personal Care) Included
l ,
Cable Television(Independent Living) $22.00/month i
Cable Internet(independent Living) $20.00/month
Cable Modem(Independent Living) $62.00 one time fee
j
Clothing Name Labels Cost
I
Guest Room(maximum stay of 5 nights) 1 person-$28.00/night
2 persons-$33.00/night
Incontinence Supplies
' Liners 25%above cost
' Briefs I Pull-ups 25%above cost
Miscellaneous supplies 25%above cost
Laundry Service(personal clothing) $33.00imonth
Photocopies(copies of records) $1.28/pg(1-20)$0.95/pg(21-60)$0.32/pg(61+) j
Therapy(physical,occupational,speech) Actual cost unless covered under Medicare or
Private Telephone co-payment by secondary insurance
Purchase Telephone Set At own expense
Monthly Line Fee $30.00/month
Hook-up,Activation,One Outlet(one time charge) No Charge
Dietary Services(guest meals; includes tax)
Breakfast $5,00
Dinner $7.65
Supper $6.30
Sundays and Holidays $7.65
Nutritional Supplies 25%above cost j
Extra Dietary Service Contact your social wormer
Medications, Medical and adaptive equipment, At own expense unless covered by your
Alarm pads,special requests,etc, insurance or covered by medical assistance I
benefits
I �
Transportation Services 0-10 Miles(round trip).......................$22.00
0-10 Miles(round trip with escort). _$44.00
f 11-50 Miles(round trip).....................
11-50 Miles(round trip with escort)...$88.00
51-76 Miles(round trip).................. $75.00
51-76 Miles(round trip with escort)..$120.00 i
Oxygen Concentrator Usage $3.00/day,unless covered under Medicare l
Portable Oxygen Usage $12.00/cylinder,unless covered under Medicare
— _ _ 6
................
Chart of Costs(continued)
Hair Care
Color rinse,set $13.00 Permanents w/conditioner $53.00
Cut,Men $11.00 Re-comb $8.25
Cut,wash,blow dry $24.50 Re-comb and curling iron $11.50
Cut,Women $11.00 Tint $28.00
Hotwax $7.00 Wash and set $12.50
Men's cut and moustache trim $12.00
Wash,blow dry $13.50
Oil treatment,shampoo, set $24.00 Men's/Women's wash in bed $15.75
Permanents $43.00 Wash,style, blow-dry in bed $26.25
Permanents in bed $58.25 Men's cut-wash $19.25
Wash,no blow dry $8.25 Mustache trim $1.25
Men's/Women's cut-wash in bed $26.75 Cut, wash and set $23.50
Color rinse $1.00
Dietary Services II
The Dietary Department offers three (3)well-balanced nutritious meals daily as well as an alternate menu
for personal preference. A PM snack is available upon request at no extra charge.
The department employs two Certified Dietary Managers and a Consultant Registered Dietician to provide
special diets and dietary consults with residents and families.
Our three-week menu cycle offers a variety of homemade items and incorporates fresh fruits and
vegetables when in season. Menus are posted in several locations throughout the Home. Our large meal
of the day is served mid-day and called Dinner. Our evening meal is called Supper,
General Guest Meal Policy
Limit four(4) guests per resident (as space permits) for all meals except holidays. Reservations must be
made 48 hours in advance for general guest meals. If reservations are not made 48 hours in advance, an
alternate guest meal may be served at the discretion of the Dietary Department,
Holiday Guest Meal Policy
On the holidays of Easter, Mothers Day, Thanksgiving, and Christmas there is a limit of two (2)guests per
resident.
Due to the volume of guests that may Wish to dine on these holidays, the Church of God Home will
accommodate the first twenty-five (25)guests to register. Since it is impossible to provide this notice to all
family members, please share this information with your extended family. Thank you for your
understanding and cooperation.
Families are encouraged to participate in special meal events throughout the year,such as our Parents
Day and Holiday Buffet,
7
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Cookies—I doz.Any Kind
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LENIGH VALLEY RESPIRATORY CARE-LANCASTER
1176 Enterprise Court-East Petersburg, PA 17520
{ (717) 569-4667, 1-800-952-134452, Fax(717)569-5555
Lehigh Valley Respiratory Care—Lancaster is an independent Nome Medical Equipment Company
providing respiratory services to Long Term Care Facilities. We are accredited by the Joint Commission of
Accreditation of Healthcare Organizations to perform Clinical Respiratory Services.
Lehigh Valley Respiratory Care—Lancaster provides Church of God Home residents with oxygen and
respiratory supplies. The Church of God Home will contact Lehigh Valley Respiratory Care—Lancaster for
these services when initially needed.
Personal Care Residents:
« Lehigh Valley Respiratory Care—Lancaster will then contact the Resident/Responsible Party to
t schedule the arrangements and discuss their billing procedures. C
• Oxygen/Respiratory Supplies may be covered under Medicare Part B as long as the qualifying
criteria have been met.
« Lehigh Valley Respiratory Care—Lancaster will contract with the Resident/Responsible Party on
I an individual basis and will bill Medicare Part B directly.
I
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MEDICAID (MEDICAL ASSISTANCE)
Medicaid provides Medical Assistance to low-income persons aged 65 or over, blind,disabled,or members
of families with dependent children. The Federal and State Governments jointly finance this program and it
is administered by the state. Within broad general Federal Regulations,each state decides eligibility,types
I and range of services,payment level of services, and administrative and operating procedures.
Medicaid's major distinction fron)Medicare is a fors of financial aide. Medicare is a type of healthcare
insurance. When resident resources are reduced to$15,000.00,the facility Business Office should be
notified immediately. The following instructions will apply:
1. Resident/Responsible party will be responsible for a burial reserve set up at a bank or funeral
home with amount equalizing enough for burial. The amount set aside should include amount of
life insurance plus additional funds. A copy of that agreement should be submitted to the Business
1 Office.
2. When all assets are reduce/to$2,000.00,call the Business Office for appointment for guidance in
the enrollment process.
r
j It is the legal responsibility of the POA/Representative Payee to complete the application and
enrollment process for Medical Assistance benefits. Every effort will be made by our Business
z Office staff to assist you. A checklist(pg12-13)is being provided to you with guidelines that will
help you get started. Please be aware however,that if the POA/Representative Payee does not
follow through in a timely manner, that the Church of God Home, Inc.reserves the right to file the
application on the resident's behalf.
3. The Centre County Office of Aging will do a level of care assessment of the resident, known as an
"Options Assessment"and forward the results to the Pennsylvania Department of Public Welfare
(DPW)for further follow-up by the Centre County Assistance Office. Should they assess for a
different level of care other than nursing, and/or the resident does not qualify for Medicaid,the
facility reserves the right to terminate the admission agreement and will work with
resident/responsible party regarding available options.
9
_I
4. To appeal a decision regarding a Medicaid Assessment,contact:
The Pennsylvania Department of Public Welfare
Centre County Assistance Office
(Cumberland County Long Term Care Unit)
2580 Park Center Blvd
State College, Pennsylvania 16801
P: (814)863-6571,800-355-6024
Fax:(814)689-1356
To appeal a decision regarding a level of care assessment,contact:
r
The Cumberland County Office of Aging
Long Term Care Program
Human Service Building
16 West High Street
Carlisle, Pennsylvania 17013
(717)240-6110
! 5. After preliminary papers are sent to the assistance office,the resident's security deposit will be
applied to room and board and any balance due billed to the responsible party.
6. After being approved, Medicaid requires that the resident's monthly income be submitted to the
i facility each month. Of that amount,the resident will receive the approved$45.00 monthly
i allowance for his/her personal needs.The resident, responsible party or the facility may handle this
personal money.
7. Allowable expense from resident monthly income is health insurance. After acceptance into the r
Medicaid program, billing for health insurance should be forwarded to the staff in our business
i
office.
{ The monthly expense for this insurance is deducted from the resident's monthly income and the
balance is applied to the room and board. The state pays the facility a per diem(daily)rate times
the number of days in the month that a resident, approved for Medicaid,occupies an
accommodation. After resident's responsibility is applied to this amount, the balance is billed to the
Pennsylvania Department of Public Welfare(DPW)on a monthly basis.
Bills for personal needs may be presented in the resident's name to the facility handling funds for
reimbursement. Upon enrollment into the Medicaid program, the resident will no longer pay for
routine hair care, incontinence supplies,non-emergent medical appointment transportation or
personal laundry service. Medicaid will, however, pay for prescription drugs,doctor visits,dental
services and eye examinations.
8. Upon transfer or discharge for hospitalization of a resident receiving medical assistance benefits,
the facility will hold a bed.
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CHURCH
OF GOD
HOME
"Commined to Caring"
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Medicaid (Medical Assistance) Residents
1. The Church of God Home, Inc.requires a copy of monthly 1 quarterly Medical Insurance premiums. As
REQUIRED by Pennsylvania State Regulations.
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2. Medical Insurance Premiums will be deducted from the Resident's monthly income and the balance of
the income less a$45.00 allowance will be applied to room and board.
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3. Prescription drugs, physician visits,dental services, and eye examinations are covered by Medicaid,
but only with participating dentists and ophthalmologists. Potential charges will be discussed with
responsible party on an individual basis,when requesting non-participating providers.
4. Services furnished at no charge to the Resident are as follows:
■ Normal Shampoo every two weeks
■ One perm every three months
* Transportation to and from medical appointments is provided (Distance to
appointments will be discussed on an individual basis)
I. • Non-emergent ambulance transportation
* Personal Laundry
• Incontinent Supplies
Bed hold in the event of hospitalization
iThe following services will be charged: '
* Any hair care request beyond the above list of provided services
* Transportation for a personal use
* Telephone hook-up, basic charges, and long distance charges
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! 5. Bed hold days due to hospitalization will be fifteen (15)days per hospital stay. Bed hold days due to
therapeutic leave will be thirty(30)days per calendar year.
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7
(Date) (Resident/ es y e 'arty)
13) Aj V
/t1.s
f
(Residen Na }
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facility 7ftsientafive)
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Medicaid(Medical Assistance)Resident's Checklist
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CENTRE COUNTY ASSISTANCE OFFICE
(Cumberland County Long Term Care Unit)
2580 Park Centre Blvd
State College,Pennsylvania 16801
Telephone: 1-800-355.6024 or(814)863.6571
In order to determine eligibility for nursing home Medicaid enrollment, the Centre County Assistance Office
f will need the following items to accompany your application when submitted by our billing office.
(Photocopies are acceptable)
Please call if you have any questions or need help in obtaining the required information.
— 1.Social Security Card(s)
2.Proof of Date of Birth
— 3.Health Insurance Cards
A. Medicare(RedMhite/Blue Card(s))
B. Capital Blue Cross/Highmark Blue Shield Card(s)
C. Any other health insurance plan(s)
— 4.Health Insurance Premiums, provide frequency and amount
f — 5.Long Term Care Policies, provide monies received and terms
6.Power of Attorney or Guardianship papers
— 7.Read HIPPA disclosure and complete the HIPAA disclosure request PW1815
q I I
8.Verification of ALL GROSS VA income needed. (If you are not receiving benefits,you will
need to apply for potential benefits in order to be eligible for Medicaid.)
I9.Vedfication of ALL GROSS income–provide current award letters, pensions, annuity income, and
interest income
10. Provide current statements for ALL bank accounts, stocks, bonds, trusts, IRAs, Keoghts, and
Annuities–must provide values of
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— 11. Personal Care Account(PCA) Balance
— 12. Verification of all resources sold,transferred,or given away during the past 5years(5 years for a
Trust Fund)–provide disposition, amounts, and dates
— 13. Titles, vehicle registration, and insurance for all vehicles owned, including boats, motorcycles,
and trailers
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14, Current cash value of all life insurance policies. Verification should include company's name,
policy number, type of policy, face amount of policy when purchased, ownership of policy, and
statement on the current cash value from the insurance company.
15. Deed to burial plot(s)or statement from cemetery
16. Copy of Burial Trust/Reserve(including Statement of Irrevocability)
17. Deed to all property and it's current market value—if transferred or sold within the last
5 years, provide a copy of the new deed and the settlement sheet for all sold property
18. Title to mobile home and it's current market value—if transferred or sold within the last
5 years, provide a copy of the new deed and the settlement sheet for all sold property
19. Any unpaid medical bills you wish to see if Medical Assistance would cover
20. Rent/Mortgage payment proof
21. Utility Bills
A. Electric
B. Gas
C. Oil
D. Heat
E. Telephone
F. Water
G. Sewer
H. Trash
22. Income Tax Returns—for the past 5 years,provide all schedules and 1099 Forms
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MEDICARE
The Church of God Home participates in the Medicare program administered pursuant to Title XVIII of the
Federal Social Security Act.
Medicare hospital insurance helps pay for inpatient care in a Medicare-participating skilled nursing facility
following a three(3)night hospital stay and your condition requires daily skilled nursing or rehabilitation
services which,as a practical matter,can only be provided in a skilled nursing facility.
A skilled nursing facility is a specially qualified facility, which has the staff and equipment to provide skilled
nursing care or rehabilitation services and other related health services.
Hospital insurance helps pay for care in a skilled nursing facility if all of the following five conditions are
met:
1. You have been in a hospital at least three nights in a row,before your transfer to a participating
skilled nursing facility.
2. You are transferred to the skilled nursing facility because you require care for a condition,which
was treated in the hospital.
3. You are admitted to the facility within a short time,generally within 30 days after you leave the
hospital.
4. A doctor certifies that you need,and you receive,skilled rehabilitation services on a daily basis,
and
I.
5. The Medicare intermediary or the facility's Utilization Review Committee does not disapprove your
stay.
All conditions must be met. It is especially important to remember the requirement that you must need
skilled nursing care or skilled rehabilitation services on a daily basis.
Skilled nursing care means rare that can only be performed by,or under the supervision of, licensed
nursing personnel. Skilled rehabilitation services may include such services as physical,occupational,and
speech therapies performed by,or under the supervision of,a professional therapist. The skilled nursing
care and skilled rehabilitation services you receive must be based on a doctor's orders.
Hospital insurance will not pay for your stay if you need skilled nursing or rehabilitation services only
occasionally, such as once or twice a week,or if you do not need to be in a skilled nursing facility to get
skilled services.
When your stay in a skilled nursing facility is covered by Medicare,hospital insurance helps pay for
up to 100 days each benefit period, but only if you need daily skilled nursing care or rehabilitation
services for that long.
14
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If you leave a skilled nursing facility and are readmitted within 30 days,you do not have to have a new 3-
night stay in the hospital for your care to be covered. If you have some of your 100 days left and you need
skilled nursing or rehabilitation services on a daily basis for further treatment of a condition treated during
your previous stay in the facility, Medicare will help pay. i
In each benefit period, hospital insurance(Medicare Part A)pays for all covered services for the first 20
days you are in a skilled nursing facility. For the 21st through the 100th day, as long as you continue to meet i
the criteria for daily Skilled Nursing Care or Rehabilitation Services, hospital insurance pays for all covered
services except for$133.50 a day. You may be charged up to this amount by the skilled nursing facility or
it may be picked up by your secondary co-insurance.
Effective May 30,2008: Medicare requires that each resident/responsible party indicate their choice with
y g
regard to a
bed hold if an nursing resident is hospitalized.
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Major services covered when you are in a skilled nursing facility I
i Medicare hospital insurance(Medicare Part A) pays for these services:
• A semi-private room, 2 beds in a room
i ■ All your meals, including special diets
■ Regular nursing services
1 ■ Rehabilitation services,such as physical,occupational,and speech therapy
' ■ Drugs furnished by the facility during your stay
■ Blood transfusions furnished to you during your stay
■ Medical supplies such as splints and casts I�
• Use of appliances such as a wheelchair
• Oxygen usage
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Some services not covered when you are in a skilled nursing facility
i
Medicare hospital insurance(Medicare Part A)does not pay for these services:
j Personal convenience items such as a telephone in your room
i Private duty nurses
IAny extra charges for a private room unless it is determined to be medically necessary
• Transportation
i Name Labels
• Hair Care
• Personal laundry service
p
! NOTE: If you disagree with a decision on the amount Medicare will pay on a claim or whether Medicare
covers services you receive,you always have the right to appeal the decision. Feel free to contact 1
1 Medicare at 1-800-633-4227. i
The Church of God Home reserves the right to withdraw from the Medicare program.
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MOBILE X-RAY IMAGING, INC.
Mobile X-Ray Imaging, Inc, ("MXI") is the most advanced, most efficient, most complete and the only local
mobile diagnostic X-Ray/Ultrasound/EKG service in Central Pennsylvania.
Based in Harrisburg, MXI employs technologists in Carlisle as well as both the East and West Shore areas
of Harrisburg, making it convenient for us to provide fast efficient service to our customers throughout the
region. We provide a broad range of mobile diagnostic services to our nursing home customers at the
nursing facility, offering the convenience and comfort of having diagnostic studies performed in the home
without the expense and discomfort of ambulance transportation. The following diagnostic services are
available on 24 hours per day,365 days per year basis:
Diagnostic X-Ray Studies Electrocardiogram Services
Holter Monitor EKG Diagnostic Ultrasound Examinations
Our X-Ray and Ultrasound exams are interpreted by Quantum Imaging and Therapeutic Associates
(formerly known as A.Z. Ritzman Associates), one of the foremost radiology physician practices in Central
Pennsylvania. All EKG and cardiology related exams are interpreted locally by Associated Cardiologists,
P.C.
MXI has introduced the following significant improvements to the mobile diagnostic testing industry in
Central Pennsylvania:
• MXI was the first provider to utilize sophisticated "high frequency" portable X-Ray units, which
produce superior images with less radiation exposure.
• We were the first mobile service in Central Pennsylvania to provide 24 hours a day, 7 days a
week X-Ray service with round the clock interpretations.
. We are the only mobile service in Central Pennsylvania, which does our own ultrasound
examinations,which gives us complete control over quality and service efficiency.
• We are the only mobile service in Central Pennsylvania to provide ultrasound service on 24
hours per day, 7 days a week basis, including interpretations.
Our services are covered by Medicare,Medicaid and most major insurances.
Mobile X-Ray Imaging, Inc.-5120 Lancaster Street-Harrisburg, PA 17111 (717)5614940
Psychiatrist
The Church of God Home, Inc. offers psychiatric services specializing in geriatric services, Philhaven
Hospital has contracted with the Church of God Home to provide on-site services for our senior adults.
Billing for this psychiatric service will be as follows:
• If the resident is private pay, Philhaven Hospital will bill Medicare first, then your supplemental
insurance. If there is still a balance,then the responsible party will be billed.
If the resident is on Medical Assistance, Philhaven Hospital will bill Medicare first, then your
supplemental insurance, and Medical Assistance third. There will be no bill to responsible parties.
Feel free to contact Philhaven Hospital at (717) 270-2413 or 1-888-740-8211 if you need further
clarification. We at the Church of God Home welcome this new dimension of expertise to our highly
qualified staff.
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Smoking Policy
j The Church of God Home does not permit smoking in any of our levels of care.
ff.
,
Residents and visitors who smoke are asked to utilize the area provided outside the main entrance for this ,
purpose. Employees and volunteers are not permitted to assist residents in meeting their smoking needs.
1 It will be necessary for residents to get assistance from their family member and friends.
All prospective residents will be informed of our Facility's smoking policy.
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Specialized Services
a physical disability,or other disability which occurred before the a of
� If you have mental retardation, p ys ty ty g
twenty-two(22),you may be eligible to receive support services that would help you to live with your family,
in your own apartment,or in another community setting. You may also be eligible for specialized services.
For more information, if you have mental retardation call Central Regional Office of Developmental
Programs at(717)772-6507. If you have another disability(other than mental retardation or mental illness)
call United Disabilities Service at(717)397-1841. I
If you have mental illness(other than dementia)and you do NOT need nursing facility services,you may be
eligible to receive support services that would help you live in your own apartment, in a group home, or
another community setting. For more information,call(717)772-7490.
If you are not satisfied with the response you receive,call the Disabilities Rights Network of PA at
(215)238-8070.
Transportation l
�. Enrollment with the local ambulance service is not required, but is recommended. Not all medical
appointments require ambulance stretcher transport and are often handled by our wheelchair lift van.
Physician ordered medical appointments are to be scheduled through our nursing department with local
physicians, as the Church of God Home does not normally transport to out-of-town medical appointments.
Family members will be contacted to determine their availability to provide transportation, or to serve as a
companion to accompany residents during transport, throughout the appointment, and on the return trip..
Medical consult sheets accompany residents to their appointments and often there is a need to adjust for a i
meal or medication routine. t
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Families providing transport are requested to follow the sign out procedures and are asked not to schedule i
follow-up appointments unless they are intending to provide the transportation. In either event,please be
sure to inform the nursing department of the scheduled follow-up appointment.
NOTE: Transportation provided by the facility will be at an extra charge. Please see"Chart of Cost"
for fee schedule.
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UNDERSTANDING RESTRAINT USE
In order to protect our residents from harm or to promote them to a higher level of independence,it is
sometimes necessary for us to use a physical restraint.
Physical restraints are any manual method, material or equipment attached or adjacent to the resident's
body that the individual cannot remove easily and that restricts freedom of movement or normal access to
the resident's body. Examples include: bedside rails, leg restraints, arm restraints,hand mitts,soft ties,
wheelchair safety bars and geri chairs. These devices are NEVER used as a disciplinary action or for the
convenience of the facility to control behavior.
Restraints are initiated only after less restrictive measures,such as positioning pillow,pads,wedges,
removable lap trays couples with appropriate exercises,or other"enabling"equipment, have been
demonstrated to be insufficient. The least restrictive device would be then implemented following a specific
doctor's order and/or a phone call to P.O.A./next of kin. The resident will then be reviewed in the next
Restraint Reduction meeting.
The following is a comparison of potential BENEFITS and RISKS of restraint use:
Potential Benefits
• Prevention of falls which might result in injury
• Protection from other accidents or injuries
• Medical treatment allowed to proceed without resident interference
• Protection of other residents/staff from physical harm
• Increased feeling of safety and security
Potential Risks
Accidental injury from the restraint
• Chronic constipation
• Incontinence
• Pressure sores
• Loss of muscle tone
• Loss of balance
• Reduced appetite,dehydration
■ Loss of independent mobility
Increased agitation
• Symptoms of depression,withdrawal
Contractures
• Reduced social contact
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rM
of
RCHGOD
HOME
"Committed to Caring,"
Advance Directive Policy
It is God alone who opens the door to earthly life. It is God alone who has the right to close it. All
experiences of life provide opportunities for evangelism, ministry, reconciliation and re-assessment of
priorities.
The Church of God Home recognizes the right of an individual to make and change decisions concerning
their medical care in consultation with their physician. This includes the right to accept or refuse artificial
means of sustaining life when these decisions are set forth in properly executed Advance
Directives/Healthcare Guidelines. In no instance will the Church of God Home condone homicide,
euthanasia, suicide or aided suicide. In the absence of advance directive,the care of the resident will be in
accordance with currently accepted medical standards. -
Regardless of the resident's decision about life sustaining treatment, supportive and compassionate care
for maximum comfort will be provided. These measures include, but are not limited to, oxygen, medication
to relieve pain,food and fluids as tolerated, along with emotional and spiritual support.
Should the occasion arise when a resident would refuse nutrition or medical supportive services with the
intention of prematurely bring their life to an end, the Home would encourage and recommend counseling
and evaluation. The family would be informed and,if a satisfactory resolution cannot be achieved as to the
care of the resident, the Home would assist the family in the attempt to relocate the resident to another
facility as soon as possible.
I acknowledge that I have received a duplicate copy of the above Advance Directive Policy and have had
provided the opportunity to ask questions relating to the same. I have also been offered the opportunity to
complete an Advance Directive.
(Date) (ResidenVfRespon e Pa
(Resides trNawe)
(Facility R resentative)
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CHURCH
OF GOD i
HOME
` "Committed to Caring"
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Complaint Procedure
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Policy: It is the policy of the Church of God Home to have a complaint procedure in place to
1
identify and address concerns.
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Purpose: To assure the Home's Mission Statement is being upheld to its highest integrity.
� Procedure:
1. Any written or oral complaints presented by or on behalf of a Resident to the Church of
God Home or DPW regarding care, operations, or management of the Home shall be
directed to the Administrator of the facility.
2. If a resident wishes to make a written complaint but needs assistance, the PCU
Administrator shall assist the resident in writing the complaint.
3. Within two(2) business days after notification of a written complaint,a status report will
be provided to the complainant and/or designated person,explaining the steps that the
Home is taking to investigate and address the complaint.
4. The Church of God Home shall ensure the Resident's safety if complaint identifies
harm or potential harm.
5, Within seven (7)days after the notification of a written complaint, a copy of the written
decision explaining the investigation findings and plans of action will be given to the
complainant and/or designated person.
6. All complaints will be placed.in a binder with the findings and plan of correction. The
PCU Administrator will maintain the binder.
(Date? esident/Respon a arty
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�- 1 NS
(Resident
(F
t
tative)
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CHURCH l
OF GOD
HOME I
"Committed to Caring"
DELEGATION OF RESPONSIBILITY FORM
As a result of medical and/or physical condition or personal choice, residents find it difficult to understand
and/or sign for their Resident's Rights and/or their Admission contract. Some residents,although not
legaily judged incompetent, may be found by a physician to be incapable of understanding these rights and
contract information. Therefore, a resident may choose to designate an individual to act of their behalf by
permitting them to sign the necessary forms indicating receipt of this information.
I
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f
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+� V Al ,h/ is medically/physically capable of
(Name of resident)
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understanding Resident's Rights but designates this to:
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(Date) (Resident(Respons arty)
iJOA/K IV-5
(Resident ame)
(Facility Rep sentative)
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CHURCH ,I
OF GOD
HOME
"Committed to Caring"
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LEGAL RIGHTS COMPLIANCE
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RESIDENTS AWARENESS
COMMONWEALTH INFORMATION CENTER PENNSYLVANIA DEPARTMENT OF AGING
4024 Finance Building
555 Walnut Street
Harrisburg, PA 17120 Harrisburg, PA 17101
Telephone: 1-800-932-0784 Telephone:717-783-7247
PENNSYLVANIA DEPARTMENT OF HEALTH PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE
DIVISION OF NURISNG CARE FACILITIES CENTRE COUNTY ASSISTANCE OFFICE
HARRISBURG FIELD OFFICE (Cumberland County Long Term Care Unit)
132 Kline Plaza, Suite B 2580 Park Center Blvd
Harrisburg, PA 17104 State College, PA 16801
Telephone:717-783-3790 Telephone: 814-863-6571
1-800-355-6024
CUMBERLAND COUNTY AGING& MID PENN LEGAL SERVICES
COMMUNITY SERVICES 401 East Louther Street
OMBUDSMAN PROGRAM Carlisle, PA 17013
I HUMAN SERVICES BUILDING Telephone:717-243-9400
I 16 West High Street
i Carlisle, PA 17013
ITelephone:717-240-6110
(Date) ( esiden #sible )
(Resident a )
(Facility Re ntabve)
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CHURCH
OF GOD
HOME
NON-DISCRIMINATION STATEMENT
in accordance with applicable Federal and State civil right laws and regulatory requirements, you, as a
resident of this facility, have the right upon admission:
To be provided services at this facility and to be referred for services at other facilities without
regard to your race,color,religion creed,handicap,ancestry,national origin,age or sex.
To file a complaint of discrimination if you feel you have been discriminated against on the basis of
your race, color, religious creed, handicap, ancestry, national origin, age, or sex. Complaints of
discrimination may be filed with any of the following:
President/CEO Department of Health and Human Services
Church of God Home, Inc. Office for Civil Rights
801 N. Hanover Street 150 S. Independence Mail West
Carlisle, PA 17013 Suite 372
Phone: (717)249-5322 Philadelphia,PA 19106-3499
Phone: (215)861-4441
Pennsylvania Human Relations Commission Department of Public Welfare
Harrisburg Region Office Bureau of Equal Opportunity
Riverfront Office Center Central Regional Office
11011-1125 South Front Street,5th Floor Rm#223, Health&Welfare Bldg.
Harrisburg, PA 17104-2515 P.O.Box 2675
Phone: (717)787-9784 Harrisburg, PA 17120-2675
Phone:(717)783-3063
4*jc-F_Al IJ AIX 4-S
(Date) identlRespo le P
(Resident mp)
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Personal Cash Accounts (PCA)
To establish personal cash account(PCA)at the Church of God Home, Inc.,contact our Business Office
(Henderson House). The following procedure shall be followed:
1. Sign the following authorization form to open an account
2. Deposit money by checks or cash-A receipt will be issued for cash deposits.
3. Daily withdraw maximum of$30.00
.to 3:45 p.m., Monday through Friday,except holidays.
Note: Regular business hours are 9:00 a.m
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D_egosits
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The resident or family member!responsible party may deposit cash or checks either at our Business Office
(Henderson House)or in our Lobby Front Office during regular business hours and of course, by mail.
Personal cash accounts are only meant to provide casual spending money for residents. -
Disbursements
The resident may come to our Lobby Front Office during business hours to request money. A resident
charge slip is completed and the resident or family member/responsible party sign the disbursement slip.
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Purchases for a resident maybe made by family or designated person and a receipt should be submitted to {
our Business Office for each reimbursement from the resident's account, i.e.TV's,shoes,clothing,etc.
PCA's are reconciled monthly to the bank statement. Interest paid by the bank is pro-rated to each account
j and deposited into each account accordingly. Quarterly statements are issued, along with a cover letter to
be signed by the resident and returned to our Business Office.
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Each resident of the facility has the right to open a personal cash account(PCA). All accounts,regardless
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of the resident's status, are handled in the same manner.
{ Upon the death/discharge of a resident,the account balance shall be returned to the executor of their Will
or authorized representative of their Estate within thirty(30)days.
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Personal Cash Accounts (cont.)
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CHURCH
OF GOD
HOME
"Committed to Caring"
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Authorization to Handle Personal Funds
1
or
(Date) (Residen'YRes nsible arty}
1
(Reside N me)
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(Facility resentabve)
1
j Depleted Funds
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When resident's assets reach $15,000.00, family/responsible party should contact our Business Office j
immediately.
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i Family member / responsible party will have to apply for Medical Assistance. Residents with no family
member/responsible party,our Business Office will apply for Medical Assistance.
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Residents will receive $45.00 monthly from their income for personal needs. Other monies may be
deposited into each PCA,as the resident or family member I nsible sir
� ( i
(Date) esident/Respo le Pa }
S
( /;7 A
Resident me}
(Faality Repre ntative}
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I CHUM
OF GOD
HOME
"Committed to Caring"
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Personal Laundry Service
This is to advise that the personal laundry will be launder within outside(circle one)the facility.
NOTE:
• These arrangements can be changed with notification to Social Services or Charge Nurse.
• Residents/Responsible Parties providing laundry services need to provide a container with a lid and
box of plastic bag liners for the purpose of storing laundry. j
• Volunteers are available to assist with labeling clothing/personal items. Please contact Social
i Services or Charge Nurse.
• pry cleaning and Alteration Services are not provided.
• No wool items are accepted.
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(Date) (Residen esponsibl q)
F �Un1 1 •+l.S
(Resident Name)
(F ility Rep sentative)
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Pharmacy Services
,F
Specialist in 28 South 2nd Street
Newport; PA 17074
Continuing Care Rx is proud to announce that we have been chosen to be the provider of choice for the
pharmacy services at Church of God Home. The mission of Continuing Care Rx is to provide pharmacy
services and programs that meet the ever-changing needs of our facilities and the residents they serve,
s ensuring continued quality care and positive outcomes in the most cost-efficient manner possible.
Pharmacy services for Long-Term Care or Personal Care Residences are mandated by government agencies
to offer additional services,which you may not have been accustomed to in a normal retail pharmacy. These
additional services are designed to aid in your progress(or that of your loved one).
We would like to highlight some of the services we provide to give you a better understanding of the many
unique benefits we have to offer the residents we serve:
• Controlled Packaging System - Routine tablet/capsule medications are packaged in a 30-day
sealed blister card enabling nursing staff to administer medications in a controlled environment with
extreme accuracy and safety. °
j ♦ Medical Records - A medical records staff member maintains and prints monthly charts that are
utilized by the caregivers, nursing staff and physicians.
♦ 24-Hour Emergency Service - If a situation occurs that requires the delivery of medications in an f
emergency; Continuing Care Rx has a pharmacist and driver on call 24 hours a day, 7 days a week
to meet these emergency needs.
{ ♦ Consultant Pharmacist—A Consultant Pharmacist is assigned to our facilities to review residents'
charts on a monthly basis and to interact with the nurses and physicians to monitor the residents'
condition. In addition, they will make recommendations to the physicians when a better and more
cost-effective therapy for the existing condition becomes available.
I
♦ Delivery Service - Medications will be delivered to the facility at predetermined times on a daily
basis,ensuring timely delivery of all medications ordered.
j ♦ Billing — The staff at Continuing Care Rx will handle the billing process for all types of
i reimbursement. Continuing Care Rx is a member of most insurance groups and we bill directly to
' these insurance groups. Should you belong to an insurance group with which we are not currently
affiliated, we will immediately pursue enrollment in that program in an effort to meet your needs and
ease your financial responsibility.
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We would like to point out that all of the above services are provided at no additional cost, thus ensuring a
much more cost-effective and beneficial way of dispensing and monitoring our residents'medications.
We, at Continuing Care Rx, are focused on providing the highest quality of pharmacy services to all of the
residents we serve. We look forward to working closely with you (or your loved one) by providing the best
service available in the long-term care industry.
Note: Please contact Continuing Care RX with any questions or billing concerns at 1-800-&75-,2179. i
27
Privacy nonce
i CONTINUING CARE RX
NOTICE OF PRIVACY PRACTICES
THiS NOTICE DESCRIBES NOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.
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PLEASE REVIEW IT CAREFULLY.
1.Our Duty to Safeguard Your Protected Health information
We are committed to preserving the privacy and confidentiality of your health information. We are required by certain state
and federal regulations to implement policies and procedures to safeguard your health information.Copies of our privacy f
policies and procedures are maintained in our business office.We are required by state and federal regulations to abide by the
privacy practices described in this notice, including any future revisions that we may make to the notice as may become '
necessary or as authorized by law.
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Individually identifiable information about your past,present,or future health or condition, the provision of health care to i
you, or payment for the health care treatment or services you receive is considered protected health information(PHi).
:accordingly, we are required to provide you with this Privacy Notice that contains information regarding our privacy �
practices to explain how;when and why we may use or disclose your PHi and your rights and our obligations regarding any
such uses or disclosures. Except in specified circumstances,we must use or disclose only the minimum amount of PHI
necessary to accomplish the intended purpose of the use or disclosure of such information.
We reserve the right to change this notice at any time and to make the revised or changed notice effective for PHi that we
already have about you as well as any information we receive in the future about you.Should we revise/change this Privacy
Notice,we will promptly post the revision[insert location,such as on a website]. You also may request and obtain a copy of
any newire-vised Privacy Notice from the contact person identified on the last page of this notice.
Should you have questions concerning our Privacy Notice,our contact information is listed on the last page of this document_
11.How We May Use and Disclose Your Protected Health information
We use and disclose protected health information for a variety ofreasons.We have a limited right to use and/or disclose your !
protected health information for purposes of treatment, payment, or for health care operations. For other uses and
disclosures,you must give us your written authorization to release your protected health information unless the law permits
ar requires us to make the use or disclosure without your authorization.
Should it become necessary to release or give access to your protected health information to an outside party performing
services on our behalf(e.g.,maintaining our computers),we will require the party to have a signed agreement with us that the
party will extend the same degree of privacy protection to your information as we do.
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The privacy law permits us to make some uses or disclosures of your protected health information without your consent or
authorization. The following describes each of the different ways that we may use or disclose your protected health
information.Where appropriate,we have included examples of the different types of uses or disclosures.These include:
1. Use and Disclosures Related to Treatment
We may disclose your protected health information to those who are involved in providing medical and nursing care
services and treatments to you.For example we may release protected health information about you to nurses,nursing
assistants; medication aides/technicians, medical and nursing students, therapists, other pharmacists, medical records
personnel,other consultants, physicians,etc. We may also disclose your protected health information to outside entities
performing other services relating to your treatment:such as long term care facilities,hospitals,diagnostic laboratories,
home health/hospice agencies,family members,etc.
2. Use and Disclosures Related to Payment
We may use or disclose your protected health information to bill and collect payment for items or services we provided
to you.For example,we in ay contact your insurance company,health plan,or another third party to obtain payment for
services we provided to you.
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3. Use and Disclosures Related to/Health Care Operations
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We may use or disclose your protected health information for the performance of certain functions in monitoring and
improving the quality of care and services that you and others receive_For example, we may use your protected health
information to evaluate the effectiveness of the care and services you are receiving. We may also disclose your protected
health information for auditing,care planning.,quality improvement,and learning purposes.
4. Use and Disclosures Related to Treatment Alternatives,Health-Related Benefits and Services
We may use or disclose your protected health information for purposes of contacting you to inform you of treatment
alternatives or health-related benefits and services that may be of interest to you,such as a newly released medication or
treatment that has a direct relationship to a treatment or medical condition.
` III.Uses and Disclosures Requiring Your Written Authorization
For uses and disclosures of your protected health information beyond the above excepted purposes,we are required to have
your written authorization,except as otherwise required or permitted by law.You have the right to revoke an authorization at
anytime to"future uses or disclosures of your information except to the extent that we have already undertaken an action
in reliance upon your authorization.Your revocation request must be provided to us in writing. Our contact information for
purposes of revoking your authorization is listed on the last page of this document You may use our Authorization for Use or
Disclosure of Protected Health Information form and/or our Revocation of an Authorization form to submit your request to
us.Copies of these forms are available upon request.
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Examples of uses or disclosures that would require your written authorization include,but are not limited to,the following:
1. A request to provide your protected health information to an attorney for use in a civil litigation claim.
2. A request to provide certain information to an insurance or pharmaceutical company for the purposes of providing
you with information relative to insurance benefits or new medications that may be of interest to you.
3. .A request to provide PH! to another individual or facility, where no exception from the written authorization
requirement applies.
IV.Uses or Disclosures of Information Based Upon Your Verbal Agreement
I� In the following situations,we may disclose a limited amount of your protected health information if we provide you with an
I advance oral or written notice and you do not object to such release or such release is not otherwise prohibited by law.
fl However, if there is an emergency situation and you are unable to object(e.g.,because you were not present or you were
incapacitated),disclosure may be made if it is consistent with any prior expressed wishes and disclosure is determined to be
in your best interest. When a disclosure is made based on these or emergency situations, we will only disclose protected
f health information relevant to the person's involvement in your care.For example,if you are having an adverse reaction to a
medication,and are not able to communicate with us effectively,we may inform a family member involved in your care of
your drug regimen and possible side effects.You will be informed and given an opportunity to object to further disclosures of
such information as soon as you are able to do so.
We may disclose your protected health information to your family members and friends who are involved in your care or
who help pay for your care.We may also disclose your protected health information to a disaster relief organization for the
purposes of notifying your family and/or friends about your general condition,location,and/or status(i.e.,whether you are
i alive or dead).You may object to the release of this information.You may use our Request to Restrict the Use or Disclosure
1 of Protected Health Information form to notify us of your objection or your objection may be made orally. Our contact
information is listed on the last page of this document.(See also Section VI,paragraph 1.)
V.Uses and Disclosures of Information That Do Not Require Your Consent or Authorization
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y State and federal laws and regulations in some instances either require or permit us to use or disclose your protected health
information without your consent or authorization. The uses or disclosures that we may make without your consent or j
authorization include the following:
1. When Required by Law:
We may disclose your protected health information when required by federal,state or local law.
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2. Abuse,Neglect,or Domestic Violence:
As required or permitted by law,we may disclose protected health information about you to a state or federal agency
i to report suspected abuse,neglect,or domestic violence. If such a report is optional,we will use our professional
judgment in deciding whether or not to make such a report. If feasible,we will inform you promptly that we have
made such a disclosure.
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3. Communicable Diseases:
To the extent authorized by law, we may disclose information to a person who may have been exposed to a
communicable disease or who is otherwise at risk of spreading a disease or condition.
4. Disaster Relief:
We may disclose protected health information about you to government entities or private organizations(such as the
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Red Cross)to assist in disaster relief efforts.
5. hood and Drug Administration(FDA):
We may disclose protected health information about you to the FDA,or to an entity regulated by the FDA,in order,
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for example,to report an adverse event or a defect related to a drug or medical device.
6. For Public Health Activities:
As required or permitted by law,we may disclose protected health information about you toa blic health
i authority,for example,to report disease,injury,or vital events such as death. pu
7. For Health Oversight Activities:
1 We may disclose your protected health information to a health oversight agency such as a protection and advocacy
agency, or to other agencies responsible for monitoring the health care system for such purposes as reporting or
! investigation of unusual incidents or to ensure that we are in compliance with applicable state and federal laws and
ILII regulations,including civil rights laws.
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S. To Coroners,Medical Examiners,Funeral Directors,Organ Procurement Organizations or Tissue Banks:
We may disclose your protected health information to a coroner or medical examiner for the purpose of identifying a
deceased individual or to determine the cause of death.We may also disclose your protected health information to a
funeral director for the purposes of carrying out your wishes and/or for the funeral director to perform his/her
necessary duties.
If you are an organ donor,we may disclose your protected health information to the organization that will handle
your organ,eye or tissue donation for the purposes of facilitating your organ or tissue donation or transplantation.
9. For Research Purposes:
We may disclose your protected health information for research purposes without your authorization only when a
j privacy board has approved the research project. We may use or disclose your protected health information to
individuals preparing to conduct an approved research project in order to assist such individuals in identifying
j persons to be included in the research project.Researchers identifying persons to be included in the research project
will not be permitted to remove protected health information from our control. if it becomes necessary to use or
disclose information about you that could be used to identify you by name,we will obtain your written authorization
before permitting the researcher to use your information. Researchers will be required to sign a Confidentiality and s
i Non-Disclosure Agreement form before being pennitted access to protected health information for research
purposes. A sample copy of this agreement may be obtained from our business office.
10. To Avert a Serious Threat to Health or Safety:_
We may disclose your protected health information to avoid a serious threat to your health or safety or to the health
or safety of others. When such disclosure is necessary,information will only be released to those law enforcement
agencies or individuals who have the ability or authority to prevent or lessen the threat of harm:
II. For Judicial or Administrative Proceedings: r
We may disclose protected health information about you in the course of a judicial or administrative proceeding,in
accordance with our legal obligations.
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12. To Law Enforcement:
We may disclose protected health information about you to a law enforcement official for certain law enforcement
purposes. For example,we may report certain types of injuries as required by law,assist law enforcement to locate
someone such as a fugitive or material witness,or make a report concerning a crime or suspected criminal conduct_ i
13. Minors:
If you are an unemancipated minor as defined under state law;there may be circumstances in which we disclose
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protected health information about you to a parent.guardian,or other person acting in loco parentis,in accordance
with our legal and ethical responsibilities.
14. Parents:
If you areaarent of an unemanci aced minor,and are acting as the minor's personal representative,we may
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disclose protected health information about your child to you under certain circumstances. For example,if we are
legally required to obtain your consent as your child's personal representative in order for your child to receive care
or services from us,we may disclose protected health information about your child to you. In some circumstances, i
we may not disclose protected health information about an unemancipated minor to you. For example,if your child
is legally authorized to obtain services(without separate consent from you),and does not request that you be treated
as his or her personal representative,we may not be required to disclose protected health information about your
child to you without your child's written authorization.
15. To Personal Representatives:
if you are an adult or emancipated minor, we may disclose protected health information about you to a personal
representative authorized to act on your behalf in making decisions about your health care. `
_ 14. For Specific Government Functions:
- We may disclose protected health infonnation about you for certain specialized government functions,as authorized
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by law_ Among these functions are the fallowing: military command;determination of veterans benefits;national
security and intelligence activities;protection of the President and other officials;and the health,safety,and security !
of correctional institutions.
17. For Workers'Compensation: ;
We may disclose protected health information about you for purposes related to workers'compensation,as required
and authorized by law.
VI.Your Rights Regarding Your Protea!Health Information
You have the following rights concerning the use or disclosure of your protected health information that we create or that we
may maintain about you:
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J. To Request Restrictions on Uses and Disclosures of Your Protected Health Information:
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You have the right to request that we limit how we use or disclose your protected health information for treatment,
payment or•health care operations.You also have the right to request a limit on the protected health information we
disclose about you to someone who is involved in your care or the payment for your care or services. For example.
l you could request that we not disclose to family members or friends information about a medicai treatment you
received.
Should you wish a restriction placed on the use and disclosure of your protected health information, you must
submit such request in writing. Such request should be submitted using our Request to Restrict the Use and
Disclosure of Protected Health Information form. Our contact information for purposes of making such a request is
listed on the last page of this document.
We are not required to agree to your restriction request. You will be informed if we decline your request. if we
accept your request, we will comply with your request not to release such information unless the information is
jneeded to provide emergency care or treatment to you.
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2. The Right to Inspect and Copy Your Health and Billing Records:
You have the right to inspect and copy your protected health information, such as your prescription and billing
records_In order to inspect and/or copy your protected health information,you must submit a written request to us.
If you request a copy of your prescription or billing information or other records,we may charge you a reasonable
fee for the paper, labor, mailing,and/or retrieval costs involved in filing your requests.We will provide you with
information concerning the cost of copying your protected health information prior to performing such service.
Such requests should be submitted on our Request fpr Inspection/Copy of Protected Health Information form. Our
i contact information for such requests is listed on the last page of this document.
We will respond within thirty(30)days of receipt of such requests. Should we deny your request to inspect and/or
copy your protected health information, we will provide you with written notice of our reasons of the denial and
your rights for requesting a review of the denial,if any.In the event of a review,we will select a licensed health care
professional not involved in the original denial process to review your request and our reasons for denial.We will 1
abide by the reviewer's decision concerning your inspection/copy requests. Your denial review request should be i
submitted on our Denial of InspectionlCopy of Protected Health Information form. Copies of these forms are
available from the contact person listed on the last page of this document.
3. The Right to Amend or Correct Your Protected health information:
You have the right to request that your protected health information be amended or corrected if you have reason to
believe that certain information is incomplete or incorrect. You have the right to make such requests of us for as
tong as we maintain/retain your protected health information.Your requests must be submitted to us in writing.We
will respond within sixty(60)days of receiving the written request,unless an extension is necessary,in which case
you will be notified,and receive a response to your request within ninety(90)days.If we approve your request,we
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will make such amendments/corrections and notify those with a need to know of such amendrnentsleorrections.
We may deny your request if:
i a. Your request is not submitted in writing;
b. Your written request does not contain a reason to support your request;
c. The information was not created by us,unless the person or entity that created the information is no longer
I available to make the amendment;
d. It is not a part of the protected health information kept by us;
e. it is not part of the information which you would be permitted to inspect and copy;and/or
£ The information is already accurate and complete.
If your request is denied,we will provide you with a written notification of the reason(s)of such denial and your
rights to have the request,the denial,and any written response(of reasonable length)you may have relative to the
information and denial process appended to your protected health information.
Your amendmenilcorrection request should be submitted on our Request for 4mendineidlCorrection of Protected
Health Information form.Copies of these forms are available from our business office. Our contact information for
the purpose of making such a request is listed on the last page of this document.
4. The Right to Request Confidential Communications:
I You have the right to request that we communicate with you about your health matters in a certain way or at a
certain location.For example,you may request that we not send any protected health information to you at a health
care facility,but instead send communication for you to a residential address or Post Office Box. We will agree to
i your request as long as it is reasonable for us to do so.
You may submit your requests on our Request for Restriction of Coodential Communications form. Copies of
:hese forms are available from the contact person listed on the last page of this document. Our contact information
is listed on the last page of this document.
5. The Right to Request an Accounting of Disclosures of Protected.Health Information:
i You have the right to request that we provide you with a listing of certain disclosures of your protected health
information that we have made over a specified period of time.This accounting will not include any information we
have made for the purposes of treatment,payment,or health care operations or information released to you,your
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family or friends for notification purposes, disclosures made for national security purposes or to certain law
enforcement officials, incidental disclosures. disclosures made as part of a limited data set (for use in research,
public health,etc.),or any disclosures made pursuant to your authorization.
I Your request must be submitted to us in writing and must indicate the time period for which you wish the
1 information(e.g.,May 1,2003 through August 31,2003).Your request may not include releases for more than six
(6)years prior to the date of your request and:may not include releases prior to April 14,2003.Your request must j
j indicate in what form(e.g.,printed copy or email)you wish to receive this information. we will respond to your
request with sixty(60)days of the receipt of your written request. Should additional time be needed to reply,you !
will be so notified. However, in no case will such extension exceed thirty(30) days. The first accounting you
request during a twelve(12)month period will be free.There may be a reasonable fee for additional requests during
the twelve(12)month period.We will notify you of the cost involved and you may choose to withdraw or modify
your request at that time before any costs are incurred.
{ You may submit your requests on our Request,for an Accounting of Disclosures of Protected health Jnformaaon
form available from our business office. Our contact information is listed on the last page of this document.
I 6. The Right to Remive a Paper Copy of This Notice:
'• You have the right to receive a paper copy of this notice even though you may have agreed to receive an electronic
copy of this notice. You may request a paper copy of this notice at anytime or you may obtain a copy of this
information from our website(as applicable). Our contact information is listed on the last page of this document. J
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Vl.How to File a Complaint About Our Privacy Practices
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If you have reason to believe that we have violated your privacy rights or our privacy policies and procedures, or if you
disagree with a decision we made concerning access to your protected health information, you have the right to file a
complaint with us or the Secretary of the U.S.Department of Health and Human Services. You will not be retaliated against I
for filing a complaint.
You may submit your complaint on our Privacy Practices Complaint form available from our business office. Our contact 1
information is listed on the last page ofthis document.
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CONTINUING CARE RX NOTICE OF PRIVACY PRACTICES
Record of Acknowledgment t Documentation of Good Faith Effort to Obtain Acknowledgment 1
Name of CResidentI tient]:—V=4e1 �R ir/�1 h1 Datc: IA "/7 —n f
Effective Date of This Privacy Notice April 14,2003
Contact Information for Questions,Complaints or Requests yarding Your Health Information
Should you have any questions concerning our privw,�y practices. obtaining a copy of our privacy notice„ requesting
restrictions on the release of your information, revoking an authorization, amending or correcting your protected health
information obtaining an accounting of our disclosures of your protected health information, requesting inspection or
! copying of your medical information,
requesting that we communicate information about your health matters in a certain
way,filing complaints or any other concerns you may have relative to our privacy practices,please contact:
Brian D.Stwaliey Chief Compliance Officer I
5775 Allentown Blvd.Suite 202,Harrisburg,PA 17112
Tel:717-8104950 Ext.4,Irax:717-810.1152
bstwaltey,,4cc rx.org
If you wish.you may also file a complaint with the Scc1dary of the U.S.D
epartmerd of Health and Hrmuttrt Services You
may mail your complaint to U.S_Department of Health and human Services,200 Independence Avenue,S.W.,Washington,
! DC 20201: or you may call (202) 619-0257 or 1877-696.6775 {toll free): or you may log on to the internet address,
http:l,'www.luhs.govlocr.
Acknowled !
gment J tC:aod Faith Effort to Obtain Acknowledgment(deck one of the following)
C J I am the above Resident/Patient and I certify that I received a copy of the Continuing Care Rx's Privacy Notice and that I
have had an opportunity to review-this document and ask questions to assist me in understanding my rights,relative to the Itt
i protection of my health information_ I am satisfied with the explanationsprovided to fire and t am confident that
Continuing Care Rx is committed to protecting my health information_
jDate: _ Signature:
Printed Name:
I certify that I am the authorized representative of above name Resic1cm/P'atiert,and that I have received the Privacy
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Notice on behalf of this individual and that Continuing Care Rx provided me with an opportumity to review this
document and ask questions to assist me in understanding the patient's privacy rights. I am satisfied with Lire
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explanations provides} to me and I am confident that the above-
entity is eotaraitted to protecting health
infamration.
Date: /�,"/ Si ature of t
grt Rep resentabive:
i Printed Narnc: f S
{ Relationship to Individual:
certify that I made a good faith effort to obtain the acknowledgment of the above-
identified(residcnt/patiemj or his/her personal representative that he/she had received a copy of the Privacy Notice of
Continuing Care Rx,but was unable to obtain such acknowledgment for the Collovring reason(s):
[Resident/Patient j or personal representative refused to sign.
( j(Resident/patient)or personal representative was unavailable to sign.
( )Other:
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Date: Signature/Tide:
Privacy xoticc
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OF GOD
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"Committed ro Caring"
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PODIATRY SERVICES
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I request that payment of authorized Medicare benefits be made either to myself,or on my behalf,to '
Dr. William Pulia for any services furnished me by that physician. I authorize any holder of medical
information about me to release to the health Care Financing Administration and its agents,any information
I needed to determine these benefits payable for related services.
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4_Yes, I have accepted Dr.William Pulic as my podiatry care physician
❑ No, I decline offered podiatry care physician for my podiatry care
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Privacy Act Statement-Healthcare Records j
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This form provides you the advice required by the Privacy Act of 1974.
This form is not a consent form to release or use healthcare information pertaining to you.
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1. Authority for collection of information including Social Security Number(SSN)
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Sections 1819(f), 1919(b)(3)(A), and 1864 of the Social Security Act
Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive, accurate,
standardized, and reproducible assessments of each resident's functional capacity and health status. As
of June 22, 1998 all skilled nursing and nursing facilities are required to establish a database of resident
assessment information and to electronically transmit this information to the State. The State is then
required to transmit the data to the federal Central Office Minimum Data Set (MDS) repository of the
Health Care Financing Administration.
This data is protected under the requirements of the Federal Privacy Act of 1974 and the MDS Long
Term Care System of Records.
2. Principal purposes for which information is intended to be used
The information will be used to track changes in health and functional status over time for purposes of
evaluating and improving the quality of care provided by nursing homes that participate in Medicare or
Medicaid. Submission of MDS information may also be necessary for the nursing homes to receive
reimbursement for Medicare services.
3. Routine Uses
iThe primary use of this information is to aid in the administration of the survey and certification of
i Medicare/Medicaid long-term care facilities and to improve the effectiveness and quality of care given in
those facilities, This system will also support regulatory, reimbursement, policy, and research functions.
This system will collect the minimum amount of personal data needed to accomplish its stated purpose.
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Privacy Act Statement-Healthcare Records (continued)
The information collected will be entered into the Long Term Care Minimum Data Set(LTC MDS)system
of records, System#09-70-1516. Information from this system may be disclosed, under specific
circumstances to:(1)a congressional office from the record of an individual in response to an inquiry j
from the congressional made at the request of that individual;(2)the Federal Bureau of Census; (3)the
Federal Department of Justice;(4)an individual or organization for a research,evaluation,or i
epidemiological project related to the prevention of disease of disability or the restoration of health; (5)
contractors working for HCFA to carry out Medicare/Medicaid functions,collating or analyzing data or to
detect fraud or abuse; (6)an agency of a State government for purposes of determining,evaluating
and/or assessing overall or aggregate cost,effectiveness,and/or quality of health care services provided
in the State;(7)another Federal agency to fulfill a requirement of a Federal statute that implements a
health benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8)Peer
Review Organizations to perform Title XI or Title XVIII functions;and(9)another entity that makes
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payment for or oversees administration of health care services for preventing fraud or abuse under
specific conditions.
4. Whether disclosure is mandatory or voluntary and effect on individual of not providing information 1
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For nursing home residents residing in a certified Medicare/Medicaid nursing facility the requested
information is mandatory because of the need to assess the effectiveness and quality of care given in
certified facilities and to assess the appropriateness of provided services. If a nursing home does not
submit the required data it cannot be reimbursed for any Medicare/Medicaid services.
i NOTE: Providers may request to have the Resident or their Representative sign a copy of this notice as a
means to document that notice was provided. Signature is NOT required. If the Resident or their
i Representative agrees to sign the form it merely acknowledges that they have been advised of the foregoing
information. Residents or their Representative must be supplied with a copy of the notice. This notice may
be included in the admission packet for all new nursing home admissions.
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I(we)acknowledge receipt of the Privacy Act Statement—Healthcare Records
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(Date) ResidentlResponsibl Pa
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(Rosi e)
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Private Room Policy- Nursing
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Policy: It is the policy of the Church of God Home that provisions shall be made for isolating a
resident in a single room whenever their medical condition requires isolation.
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Purpose: To ensure that the resident receives the most suitable protection possible.
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Procedure:
1. The one private nursing room in this facility may be used as a regular private/single room IiI
until the facility's need for an isolation room arises. This room is identified as Room 118 1
Faith Wing.
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2. Any resident using room 118 must agree on admission that they will move out of the
room to a semi-private room if the facility needs to use it.
3. When a need for an isolation room arises and a semi-private room is not available at
Church of God Home,the resident occupying the private room will be transferred as
soon as possible temporarily to another long-term care facility until a semi-private room
becomes available at the Church of God Horne. This individual will then be returned to
the private room when it again becomes available.
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4. Individuals interested in occupying a private room should make their interest known on I
admission to the Director of Admissions or their Social Worker at anytime.
b. The Director of Admissions will maintain a list of those residents interested in the private
room. Such resident Will be offered the private room,when available, based on their
initial admission date to the Church of God Horne, regardless of their level of care or the
date they placed their name on the waiting list.
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' 6. When not in an isolation need situation, a resident in the private room must be of private
pay status. If no longer able to cover the monthly bill,such resident will be asked to
relocate into a semi-private room as soon as an appropriate one becomes available at i
the Church of God Home.
(Date) en espon ' e PartyVL�ZADF,,PAJJUNK
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(F;dli Re sentative)
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"Committed to Caring"
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Therapy
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Church of God Home has arranged for Genesis Rehabilitation Services, a professional, full-service therapy
company, to provide physical, occupational, and speech therapy services. These services will be provided `
i only when the Resident's physician orders them, and when these services are necessary to attain or maintain
the Resident's highest practicable physical, mental and psychosocial well being. While the payment of
charges for therapy services is the responsibility of the resident, insurance will usually pay for such services.
If the resident has Medicare Part B coverage, Medicare Part B will pay for 80%of the therapy charges. The
balance of the 20%may be paid by the Resident's supplemental insurance. in the event therapy services are j
not covered, the Resident will be billed privately. Residents should review the coverage for therapy under i
their plan, and, if necessary, call the insurance company. Residents / Responsible Party may contact our i
Business Office with questions related to therapy billing. a
l
The u ersigned hereby consents to the provision of therapy services for i
(the Resident)
as ordered by Resident's physician and deemed necessary to attain or maintain the highest practicable
physical, mental and psychosocial well-being. The undersigned understands that no guarantee or assurance
has been made as to any result that may be obtained from the Resident's treatment. The undersigned
authorizes Church of God Home, Genesis Rehabilitation Services, and the Resident's treating or consulting
physicians to release necessary records needed for the provision of therapy services or for payment. I
i (�a'e) (ResidenURespons' e P )
(Reside Name)
I
i (Facility R resentalive)
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_ i
..........
Vaccinations
I
INFLUENZA (FLU)
�.
i Key Fads About Seasonal Muem(Flu)
What is Influema(Also Called Flu)?
The flu is a contagious respiratory illness caused by Influenza viruses.It can cause mill to severe illness,and i
at times can lead to death.The best way to prevent the flu is by getting a flu vaccination each year.
Every year in the United States,on average:
i
5%to 20%of the population gets the flu; li
• more than 200,000 people are hospitalized from flu complications;end
• about 36,000 people die from flu.
Some people.such as older people,young children.and people with certain health conditions(such as
asthma,diabetes,or heart disease),are at high risk for serious flu complications.
1 Symptoms of Flu
Symptoms of flu Include:
• fever(usually high) . runny or stuffy nose
• headache • muscle aches
• extreme tiredness • Stomach symptoms,such as nausea,
• thY Gough vomiting,and diarrhea,also can occur but
• sore throat are more common in children than adults
Complications of Flu
Complications of flu can include bacterial pneumonia,ear infections,sinus infections,dehydration,and
worsening of chronic medtGal conditions,such as congestive heart failure,asthma,or diabetes.
How Flu Spreads
Flu viruses spread mainly from person to person through coughing or sneezing of people with influenza. {
Sometimes people may become infected by touching something with flu viruses on it and then touching their f
i mouth or nose.Most healthy adults may be able to infect others beginning 1 day before symptoms develop 1J
and up to 5 days atter becoming side.That means that you may be We to pass on the flu to someone
else before you know you are sick,as well as while you are sick.
iPreventing Seasonal Flu:Get Vaccinated
{ The single best way to prevent the flu is to get a flu vaccination each year.There are two types of vaccines:
I
• The"flu shot —an inactivated vaccine(containing kilted virus)that Is given with a needle.The flu
shot is approved for use in people 6 months of age and older,including healthy people and people
i with chronic medical conditions.
Page 1 of 3
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
CE14VCRS FOR DISEASE CONTROL ANO PREVENTION
SAFER-HEALTHIER-PEOPLE"
i
40 _
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• The nasal-spray flu vaccine—a vaccine made with live,weakened flu viruses that do not cause the
flu(sometimes called LAIV for'Live Attenuated Influenza Vaccine*).LAIV is approved for use in
healthy*people 2-49 years of age who are not pregnant.
About two weeks after vaccination,antibodies develop that protect against influenza virus infection.Flu
vaccines will not protect against Mike illnesses caused by non4nfluenza viruses.
When to Got Vaccinated
Yearly flu vaccination should begin in September or as soon as vaccine is available and continue throughout
the influenza season,into December,January,and beyond.This is because the timing and duration
of Influenza seasons vary.While influenza outbreaks can happen as early as October,most of the
time Influenza activity peaks in January or later.
Who Should Got Vaccinated?
In general,anyone who wants to reduce their chances of getting the flu can get vaccinated.However,certain
people should get vaccinated each year either because they are at high risk of having serious flu-related
complications or because they live with or care for high risk persons.During flu seasons when vaccine supplies
are firrifted or delayed,the Advisory Committee on Immunization Practices(ACIP)makes recommendations
regarding priority groups for vaccinating.
People who should get vaccinated each year are:
1. People at high risk for complications from the flu,Including:
• Children aged 6 months until their 5th birthday,
• Pregnant women,
• People 50 years of age and older,
• People of any age with certain chronic medical conditions,and
• People who live in nursing homes and other long-term care facilities.
2. People who live with or cam for those at high risk for complications from flu,including.
• Household contacts of persons at high risk for complications from the flu(see above).
• Household contacts and out of home caregivers of children Less than 6 months of age(these children
are too young to be vaccinated),and
Health care workers.
3. Children aged 6 months up to their 19"'birthday
4. Anyone who wants to decrease their risk of influenza.
Use of the Nasal Spray Flu Vaccine
Vaccination with the nasal-spray flu vaccine is an option for healthy*people 2.49 years of age who are not
pregnant,even healthy persons who live with or care for those in a high-risk group.The one exception is
healthy persons who care for persons With severely weakened immune systems who require a protected
environment;these healthy persons should get the inactivated vaccine. II
Page 2 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
SAFER•HEAP-THIER-PEOPLIC"'
41
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I
E
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j Who Should Not Be Vaccinated
Some people should not be vaccinated without first consulting a physician.They include: I
I
. People who have a severe allergy to chicken eggs_ i
• People who have had a severe reaction to an influenza vaccination in the past.
People who developed Gu'ftj ain-BarrL&syndrometGOSI within 5 weeks of getting an influenza vaccine
previously_
Children less than B months of age(influenza vaccine is not approved for use in this age group).
. People who have a moderate or severe illness with a fever should wait to get vaccinated until their
I symptoms lessen.
If you have questions about whether you should get a flu vaccine,consult your health-care provider.
i
For more about preventing the flu,see the following:
. Key Facts About Seasonal Flu Vaccine
• Influenza Antiviral Drugs
. Good Health Habits for Prevention
. The Flu:A guide for Parents
'Healthy"indicates persons who do not have an underlying medical condition that predisposes them to
Influenza complications.
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f
For more Information,visit www.cdc.gov/flu,or call CDC at
800-CDG-INFO(English and Spanish)or 888-232-6348(TTY).
Page 3 of 3
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION
SAFER-HEALTHIER-PEOPLE"
42
I
PNEUMOCOCCAL
POLYSACCHARIDEVACCINE
i
WHAT YOU NEED TO KNOW
Mary vaocinw wmmaffan a lawn are aMistie in Sw*h and near WVU99M 590 W"-immr n.cW"
Why get vaccinated? --� 3 Who should get PPV?
Pneumococcal disease is a serious disease that • All adults 65 years of age or older.
causes much sickness and death.In fact,
pneumococcal disease kills more people in the Anyone over 2 years of age who has along-
United States each year than all other vaccine- term health problem such as:
preventable diseases combined.Anyone can get -heart disease
pneumococcal disease.However,some people are -lung disease
at greater risk from the disease. These include -sickle cell disease
people 65 and older,the very young,and people -diabetes
with special health problems such as alcoholism, -alcoholism
heart or Iung disease,kidney failure,diabetes,HIV -cirrhosis
infection,or certain types of cancer. -leaks of cerebrospinal fluid i
Pneumococcal disease can lead to serious
Anyone over 2 years of age who has a disease
infections of the lungs(pneumonia),the blood or condition that towers the body's resistance
(bacteremia),and the covering of the brain to infection,such as:
(meningitis).About 1 out of every 20 people who -Hodgkin's disease f
get pneumococcal pneumonia dies from it,as do
about 2 people out of 10 who get bacteremia and 3 -lymphoma,leukemia-kidney failure
people out of 10 who get meningitis.People with -multiple myeloma
the special health problems mentioned above are -nephrotic syndrome
f even more likely to die from the diease. �HIV infection or AIDS
Drugs such as penicillin were once effective in -damaged spleen,or no spleen
treating these infections;but the disease has -organ transplant
become more resistant to these drugs,making
I treatment of pneumococcal infections more - Anyone over 2 years of age who is taking any
idifficult.This makes prevention of the disease drug or treatment that lowers the body's
through vaccination even more important. resistance to infection,such as:
-long-term steroids
? -certain cancer drugs
Pneumococcal polysaccharide
-radiation therapy
vaccine(PPV) Alaskan Natives and certain Native American
The pneumococcal polysaccharide vaccine(PPV) populations.
protects against 23 types of pneumococcal
1 bacteria.Most healthy adults who get the vaccine j
develop protection to most or all of these types {
within 2 to 3 weeks of getting the shot.Very old
people,children under 2 years of age,and people
with some long-term illnesses might not respond pneumococcal Polysaccharide
as well or at all.
I
43
-- _ -- -
i
How many doses of PPV��D
Less than 1%develop a fever,muscle aches,or more
f 4 needed? severe local reactions.
Usually one dose of PPV is all that is needed. Severe allergic reactions have been reported very rarely.
However,under some circumstances a second dose may As with any medicine,there is a very small risk that
serious problems,even death,could occur after
be given.
i getting a vaccine.
• A second dose is recommended for those people aged
Getting the disease is much more likely to cause
65 and older who got their first dose when they were
under 65,if 5 or more years have passed since that serious problems than getting the vaccine.
idose. Preactionl hat if there is a serious
A second dose is also recommended for people who:
j have a damaged spleen or no spleen
-have sickle-cell disease What should I look for?
I have HIV infection or AIDS 'Severe allergic reaction(hives,difficulty breathing,
have cancer,leukernia,lymphoma,multiple myeloma shock),
have kidney failure What should I do?
have nephrotic syndrome •Call a doctor,or get the person to a doctor right
have had an organ or bone marrow transplant away-
are
wayare taking medication that lowers immunity .Tell your doctor what happened,the date and time
Ii (such as chemotherapy or long-term steroids) it happened,and when the vaccination was given.
Children I0 years old and younger may get this Ask your doctor,nurse,or health department to
second dose 3 years after the first dose.Those older report the reaction by filing a Vaccine Adverse Event
than 10 should get it 5 years after the first dose. Reporting System(VAERS)form.
Or you can file this report through the VAERS web
( Other facts about getting the site at www vaen.org,or by calling 1-800-822-7467.
vaccine � VAERS dons not provide medical advice.
k Otherwise healthy children who often get ear
infections,sinus infections,at other upper $ 1 How can I learn more?
respiratory diseases do not need to get PPV because .Ask your doctor or nurse. They can give you the
of these conditions, vaccine package insert or suggest other sources of
1 ° PPV may be less effective in some people,especially information.
I those with lower resistance to infection.But these .Cali your local or state health department.
people should still be vaccinated,because they arc .Contact the Centers for Disease Control and
more likely to get seriously ill from pneumococcal
disease. Prevention(CDC):
• Call 1.860-232-4636(1-800-CDC-MM)or
• Pregnancy:The safety of PPV for pregnant women Visit the National Immunization Program website
i has not yet been studied.There is no evidence that at www.cdc.gov/vaceines
the vaccine is harmful to either the mother or the
ferns,but pregnant women should consult with
their doctor before being vaccinated.Women who
are at high risk of pneumococcal disease should be
vaccinated before becoming pregnant,if possible.
� What are the risks from PPV?
J�
PPV is a very safe vaccine.
DEPART7tENT OF HEALTH AND HUNAft ilRltlttil6 f
About half of those who get the vaccine have very mild CENTERS FOR DISEASE CONTROL AND PREVENTION
side effects,such as redness or pain where the shot is
given. Pneumococcal Vaccine Information Statement
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CHURCH
OF GOD
HOME
"Committed to Caring"
Vaccinations
The Church of God Home administers flu vaccine on an annual basis for all residents of our facility. Annually
the Tri-Valent Influenza Vaccine will be offered, prior to the beginning of flu season, for all residents who
provide written authorization themselves or by his/her responsible party.
A resident cannot receive the Tri-Valent Influenza if they are allergic to eggs or egg products. Otherwise, the
Tri-Valent Influenza has proven to be generally safe and effective, If you desire to receive the Tri-Valent
Influenza vaccine and/or the pneumonia vaccine,please complete the authorization below.
Kj---Tdo authorize that the Tri-Valent Influenza vaccine be given annually per facility protocol.
❑ No, I do not wish to receive the Tri-Valent Influenza at any given time.
❑ I have received literature pertaining to the benefits of the Tri-Valent Influenza vaccine.
The Church of God Home also offers a vaccine that provides effective protection against the Pneumococcal
form of pneumonia, This vaccine will be available to those residents who desire it and are medically eligible.
If you have any questions, you may discuss them with your personal physician r the Church of God Home
physician who monitors your care.
r=e -----l-do authorize that the Pneumococcal Pneumonia vaccine be given.
E, No, I do not wish to receive the Pneumococcal Pneumonia vaccine at any given time.
❑ I have received literature pertaining to the benefits of the Pneumococcal Pneumonia Vaccine.
If known,please indicate the date when the vaccines listed below were last received:
Tri-ValentlnOuenza vaccine:
7
Pneumonia Vaccine,
Tetanus Vaccine: PIC-
(Date) (ResidentResponLde Par4�
J-VAII< I A15
(Resi*nt me)
(Facility
(Facility presentative)
45
F
CHS
OF GOD
HOME
Tommitted to Caring"
I
Valuables ,
The Church of God Home desires to administer quality care for all of our residents,focusing on a high quality
i of life. We do want to avoid any unfortunate situation that could result in any financial or emotional loss to M
residents and/or families. Our Home has not had many such losses,but when they happen,it is tragic.
To minimize the risk of loss,the Church of God Home recommends that residents have no more than five
dollars($5.00) at any one time in their possession or rooms, and keep no valuables, real or intrinsic, in their
rooms. By signing this paper you acknowledge being informed of the Home's recommendations.Some
people have wisely substituted zircons for diamonds and kept the settings.It is the responsibility of the
res?dent or the responsible party to have items of value independently appraised and insured, if so desired to
cover potential damage to or loss of personal property. If damage or loss occurs to the residents property,
the Church of God Home will investigate each incident of loss or damage to determine liability and assess
depending on the facts and circumstances of each incident.The Church of God Home shall be responsible
for only such losses or damages as are attributed by the Home due to the negligence of the Home.
1
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l. (Date) esident/Responsibl a )
{
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., v 1 Al-35
,I
(Reside Name)
I (Facility R resentative)
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CHURCH OF GOD HOME, INC.
ADMISSION AND CARE AGREEMENT
is and between the
THIS AGREEMENT is made on this da 20Abby
�o` &CJU it�WrpOration located at 801 North
Church of God Home,Inc.,called the"Facility,"a Pennsylvania non-pro
Hanover Street, Carlisle, Cumberland County, Pennsylvania,and
called'Resident"and Jk—1,1/_$ called"Responsible Party".
The Resident and the Responsible Party reaffirm that the information provided in the Pre-Admission
Questionnaire is true and correct and understand that the submission of false information may constitute
grounds to terminate this Agreement. The Resident has applied for admission to the Facility and the Facility
has approved the Application for Admission. Therefore,the Facility and the Responsible Party agree to the
following terms:
1 PROVISION OF SERVICES-The Facility will provide Resident with:
a. Skilled nursing care,i.e. professionally supervised nursing care and related health services under
a plan of services regularly provided under a plan of care supervised by licensed personnel and,
as required by the Residents medical condition, assistance with activities of daily living.
b. Accommodations consistent with the level of care provided to the Resident including heat, air
conditioning,electricity,hot,and cold water.
c. Bed,bedding, blankets,laundered bed linens,towels,and washcloths.
d. Three meals each day except as otherwise medically indicated.
e. Activity programs,Spiritual programs,and Social Services.
2, RECURRING CHARGES-In exchange for the above services,the Resident shall pay the following
recurring charges:
a. For skilled nursing care: dollars per day.
3. SECURITY DEPOSIT-The Resident shall pay the following non-recurring charges:
a. A security deposit in the amount of thirty-one(31)times the current daily rate for the level of care
required by the resident,will be billed after admission day. The amount of the security deposit is
$_?1 security will charged
).&. No interest will be paid on the security deposit. A secu deposit 11 not be
to residents who are receiving benefits for room and board provided by Medicare,until the
Medicare benefit concludes. An applicant who is covered by Medicaid is not required to pay a
1 security deposit.
b. If the admission to Nursing Care is the result of a level of care change from Assisted Living,the
Resident will be billed the difference between the two Security' Deposit rates. - I
c. The security deposit for private pay residents, after deductions for the payment of any
outstanding bills owed to the Facility,will be refunded within thirty(30)days after the Resident's
discharge or death. Upon discharge or death the following refund policy will be followed:
i. Thirty(30)days—Private Pay
ii. Ninety(90)days—Medicaid
iii. Thirty(30)days—Personal Cash Account
There will be no other refunds,in the absence of an over payment,under this Agreement.
4. MISCELLANEOUS CHARGES AND OUTSIDE SERVICES-Resident is responsible to pay for other
services provided by the Facility,which are not covered by the daily ratelcharge, A list of such
services charges is attached to this Agreement on the'Chart of Costs."
47
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Admission and Care Agreement-continued
The services of a licensed physician and dentist,a registered pharmacist and licensed pharmacy for the
provision of pharmaceutical supplies, a licensed hospital, and diagnostic services,will be made available at
the Resident's expense.
The resident has the right to select his/her own physician or any other service provider so long as the
physician or other service provider is properly licensed or registered under the law,and that all applicable
government rules and policies of the Facility are met.
In addition to the Facility's charges,the Resident is responsible to pay all fees and costs for goods or
services furnished to or for the Resident by anyone other than the Facility under this Agreement. The
responsibility of the Resident to pay applies to all fees for costs of services provided for the Resident by any
physician,dentist,optometrist,therapist,diagnostic or resting laboratory,pharmacist,pharmacy, hospital,or
any other person,facility or entity providing services or goods to or for the Resident, and for all drugs,
medicines,medications, pharmaceutical supplies,corrective eye lenses, hearing aids,dentures,hair care,
and other personal items or services for the Resident. Such fees and costs are not included in the Home's
daily rate/charge.
5. ADMISSION-The Resident will be admitted,or a bed will be reserved for Resident,beginning on
1:X—L S 09 All pre-admission charges will be billed after admission, and
recurring charges will begin to accrue as of the above date.
The Resident may reserve an available bed by paying the daily rate for the bed reserved. The daily
rate for the reserved bed will continue to accrue and be payable until the reservation is terminated,
even if the Resident does not enter the Home for whatever reason,including illness,injury, incapacity
or death.
6. PERIODIC BILLINGS AND PAYMENT DUE DATE
a. On the first of each month, Resident will be billed the current daily rate for Residents current
level of care times the number of days in the month. The bill is due and payable upon receipt.
d. Miscellaneous charges(refer to"Chart of Costs"attached to this Agreement)such as hair care,
personal laundry, incontinency,supplies,etc., are additional charges above the daily rate. These
miscellaneous charges will be added to,and included with,your monthly bill.
e. Pharmacy changes will be billed as a separate part of the Facility's monthly bill,and will require a
separate check.
f. Outside providers will bill directly and separately.
7. CHANGES IN CHARGES-From time to time,the Facility may change the amount of its charges. In
addition,from time to time,the Facility may change how and when its changes are computed, billed
or become due. The Facility reserves the right to make any such changes at any time. Written
notices of any such changes will be given to the Resident thirty(30)days in advance of
implementation,unless the change is required earlier under any federal or state law or assistance
program.
8. "MEDICARE/MEDICAID" PROGRAM-The Facility participates in the Medicare program
administered pursuant to Title XVIII o f the Federal Social Security Act and the Medicaid (Medical
Assistance) Program administered pursuant to the Pennsylvania state plan and Title XIX of the
Federal Social Security Act. However,the Facility reserves the right to withdraw from the
Medicare/Medicaid program at any time in accordance with the law.
46
Admission and Care Agreement.continued ,
9. OBLIGATIONS OF RESPONSIBLE PARTY The Responsible Party is responsible for services and
supplies that are billed through the Facility directly to the Resident, Responsible Party,or by any
other provider. The Responsible Party is responsible to pay all fees and costs from Resident's
resources. In the event of an emergency the Responsible Party is asked to leave an emergency
contact telephone number(s). (i.e. when vacationing)
10. READMISSION—BED HOLD POLICY-If the Resident leaves the Facility for a period of
hospitalization,therapeutic leave,or any other reason,other than the Resident's death, and if the
Resident is not eligible for,or receiving medical assistance,the Resident's bed will be reserved and
changes for the reserved bed will continue to accrue unless the Resident or Responsible Party
otherwise directs in writing. If the Resident or Responsible Party elects not to reserve a bed,then the
Resident will be eligible for readmission upon the availability of the first bed suitable for the I
Resident's level of care.
i If the resident is receiving medical assistance benefits and the Resident leaves the Facility for a
period of hospitalization or therapeutic leave,the Resident's bed will be reserved for the applicable
maximum number of days paid for the reserved bed under the Medicaid(Medical Assistance) !
Program. The current bed reservation period is fifteen(15)days for hospitalization,fifteen(15)days
j for therapeutic leave for residents receiving skilled nursing care,and thirty(30)days for therapeutic f
leave for residents receiving nursing care. The bed reservation period may be subject to change in
accordance with any changes in the Medicaid (Medical Assistance)Program. If the period of j
hospitalization or therapeutic leave ends within the reservation period under the Medicaid (Medical
Assistance)Program,the Resident may return to the Facility. If the period of hospitalization or
therapeutic leave exceeds the maximum time for reservation of a bed under the Medicaid (Medical
Assistance)Program,the Resident must wait until a suitable bed becomes available for readmission.
The Resident is entitled to the first available bed suitable for the Resident's level of care if, at the time
of readmission,the Resident requires the services provided by the Dome.
Effective May 30,2008, Medicare requires that each resident/responsible party indicate their choice
th regard to a bed hold if any nursing resident is hospitalized.
j [R..Y—es, I would request a bed hold. I understand that I will be billed at the standard daily rate.
I ❑ No, I do not wish to hold a bed in the event of a hospitalization. I understand that by doing
so,the bed may no be available for readmission.
❑To be determined at time of hospitalization.
11. REFUNDS-The security deposit for private pay residents,after deductions for the payment of any a
outstanding bills owed to the Facility,will be refunded within thirty(30)days after the Resident's ;
E discharge Facility or death. Residents receiving Medicaid will receive a refund, if any due,within
ninety(90)days. There will be no other refunds, in the absence of an overpayment, under this
i Agreement.
i
t 12. PERSONAL FINANCES-The Resident has the right to manage his/her personal funds. The
Resident is and will be responsible to provide his/her personal funds. If the Resident elects,the
Resident may designate,in writing,that the Facility hold and manage the Resident's personal funds.
If the Resident designates someone other than the Facility to manage his/her personal funds,the
Resident or Responsible Party shall notify the Facility promptly. The Resident is not required to
make any designation,and is responsible for his/her own personal funds unless such designation is
made.
i 49
Admission and Care Agreement-continued
1
f
The Resident may revoke,at any time,the designation of the Facility as the manager of his/her
personal cash account by providing the Facility a written notice signed and dated by the Resident or
Responsible Party.
If the Resident transfers to the Home,responsibility to manage the Resident's personal funds, the
Facility will do so in accordance with the"Rights of Nursing Facility Residents", a copy of which is
provided at the time of your admission.The Facility may deduct, at any time,charges due the Facility
under this agreement from the Resident's personal funds managed by the Facility.
i
13. TERMINATION,TRANSFER DISCHARGE,OR LEAVE OF ABSENCE
I
j a. B the a Resident. The Resident may terminate this Agreement upon thirty(30)days written
notice to this Facility. If the Resident leaves the Facility for any reason other than a medical
emergency or death,the Resident must give written notice to the Facility at least thirty(30)days
i in advance of the departure/transfer/discharge or termination of the Agreement. If advance
written notice is not given to the Facility,there will be due to the Facility it's daily and other
changes then in effect for the Resident's current level of care for the required thirty(30)day
notice period. The charge applies whether or not the Resident remains at the Facility during the I
thirty(30)day period.
b. By the Facility; The Facility may terminate the Resident's stay and transfer or discharge the
Resident if:
i. The transfer or discharge is necessary to meet the Resident's welfare which cannot be bet
by the Facility;
ii. The Resident's health or condition has improved sufficiently that the Resident no longer
needs the services provided by the Facility;
iii. The safety or health of individuals in the Facility is or otherwise would be endangered;
iv. The charges or other amounts due the Facility under this Agreement have not been paid to
the Facility or treated as paid to the Facility on the Resident's behalf the Pennsylvania
Medicaid Program or Federal Medicare benefits under Title XViIi or
v. The facility ceases to operate.
The Facility generally will notify the Resident and Responsible Party or if none,a family member of
i legal representative of the Resident,if known to the Facility, at least thirty(30)days in advance of
a such a transfer or discharge. However,in any case,described in subparagraph (i), (ii)or(iii)above,
or if the Resident has not resided at the Facility for at least thirty(30)days,the Facility will give such
notice before transfer or discharge as is practicable under the circumstances.
50
Admission and Care Agreement-continued
14� THIRD PARTY PAYMENTS-The Resident may be or may become eligible to receive financial
assistance,reimbursement or other benefits from third-parties,such as through private insurance,
employee benefit plans. Medical assistance under the Pennsylvania Medical Assistance Program,
Medicare benefits, supplementary medical or other health insurance,supplemental security income
insurance,or old age survivors'or disability insurance under or pursuant to the Federal Social
Security Act or Program. If the Resident becomes eligible to receive payments from any third-parties
for the stay and care of the Resident,the Resident/Responsible Party shall,at all times,cooperate
fully with the Facility and each third-party payments.Cooperation includes,when requested,
providing information,signing and delivering documents, and having the Facility designated by the
Social Security Administration as the Residents representative payee for receipt of Federal Social
Security benefits or any other governmental assistance, reimbursement or benefits to the extent of all
charges due the Facility.The Resident irrevocably authorizes the Facility to make claims and to take
such other actions as maybe necessary for the Facility's receipt of third-party payments. To the
fullest extent permitted by law,the Resident hereby assigns now or hereafter payable to the extent of
all charges due to the endorse and turn over to the Facility any payments received from third-parties
to the extent necessary to satisfy the charges under this Agreement.
15. PERSONAL PROPERTY-The Resident/Responsible Party is and will be responsible to furnish and
maintain clothing,jewelry, personal possessions,and other items of property.The facility may limit
the amount or type of property that the Resident may keep at the facility if there is insufficient space,
or if medically indicated or necessary to protect the rights or welfare of others.All non-clothing items
of value must be recorded on the residents personal inventory located with their medical record on
the day of admission or any day thereafter. The same is true if removing an item of value from the
resident's room.You are requested to see the charge nurse/social worker regarding resident's
personal property. If nametag labels are needed for clothing items, please leave them at the nursing
station.
16, RESPONSIBILITIES OF RESIDENT-The Resident shall comply fully with all governmental laws
and regulations,the provisions of this Agreement and the facility's existing policies,rules and.
regulations which may,from time to time,be altered or amended.
17, MISCELLANEOUS PROVISIONS
a. The Resident and Responsible Party acknowledge that they are adult individuals and have
read and understand the terms of this Agreement.
b. The provisions of this Agreement shall be governed by the laws of the Commonwealth of
Pennsylvania and shall be binding upon and inure to the benefit of each of the undersigned
parties and their respective heirs, personal representatives, successors and assigned.
c. The various provisions of this Agreement shall be severable one from another. If any
provision of this Agreement is found by competent legal authority to be invalid,the other
provisions shall remain in full force and effect as if the invalid provision had not been part of
this Agreement.
51
Admission and care Agreement-continued
d. The Facility reserves the right to modify unilaterally the terms of this Agreement to conform
to subsequent changes in the law or regulation and changes in charges. Resident will be
provided thirty(30)days written notice of changes in charges and, if practicable, reasonable
notice of any modifications required by law.
tz 4-9
(Date) ;eesidenttRespons' Pa )
4
i
AM(w
(Resident arae)
I
(Facility R resentative) ,
I
)
i
62
RESIDENT I FAMILY GUIDE TO INQUIRIES AND INFORMATION
i
+ L
C dd
Q 131
t0 cs E ri .V_CN
0in
InqJlres ° '�
C
0 L L
o f v
4 x EO 0 u 0 0 Mar z � xQ rn +v > ca
Healthcare
Personal Care x
Admissions
Independent
1 Living x
Admission
i Billing Question X
I Medicare X
Question
Applying for X
Medicaid
Pharmacy Billing X
Laundry Billing X
Donation Monetary X
Donation Other X
Personal Cash
Account x
Questions
Personal Cash
Deposits/ X
Withdrawals
Guest Meal
Reservations X
Party
Reserving of Lounge x
Family Concerns
X
HIPPA Changes
� X
Coordinate Change
in Level of,Care x
Resident Lost Items
j X
' Telephone
Cable x
Hook-up
I LeTort X
Guest Suite
t
a
53
RESIDENT I FAMILY GUIDE TO INQUIRIES AND INFORMATION
o H = yon H +ooE = c°R :: o
CL
E t3 n v0 fu m m 0 c
olfqUifES U)z m am
Change in Laundry X
Service
Transport X
Requests X
Special Hair Care
Requests,Payment
Scheduling X
Resident Care `
X
i Resident Medication X
r
Physician Questions X
i Therapy Questions
i X
' Taking Residents X
Out of Facility
Change in POA
Contact X '
Address/Phone
Change in POA X
i
Health Insurance X
Cards
Religious Questions
X
Funeral Questions
X
Funeral Procession
Service X
Memorial Services f
' X
"The Orchards"at
Marsh Run X
i
i
t
I
54 4
` i i
..............
Facility Mailing Address: 801 North Hanover Street
Carlisle, PA, 17013
Facility Main Telephone#: (717)249-5322
Facility Administrator:....................Susan Bower, NHA -................. ........... .......... ............. ....ext. 3086
-------------------------------------------------------------
Activity Dept.: ..............Amy Findon, CTRS.................................................................ext.3021
(Director of Activities)
Business Office: ❑..............Sharon Cramer(Business Office/Henderson House)........................ext.3032
r.Billing A/R Specialist-Personal Cash Accounts)
.........Michele Shughart(Business Office/Henderson House)......................ext.3095
(Billing Specialist-Medical Assistance)
Care Plan: ❑..............Lynne Shellenberger, RN(Mig. wAn 14 days of Admission)...ext.3033
(Nursing Assessment Coordinator-RNX)
Chaplain: ❑. ............Pastor Bradley Moore............................._.............................ext. 3022
Dietary: ❑. ............Bradley Weiser............................................... .......................ext. 3022
(Director of Dining Services)
HairCare: ❑. ............Joan Ludwig...........................................................................ext.3003
(Director of Hair Care)
Medical Appts.: El..............Jessica Dietz.. ext.3961
(Nursing Administrative Assistant)
Nursing Dept.: R..............Mary Hartman, 8N, BSN........................................................ext. 3015
(Director of Nursing)
R..............Faith Long Hall(#io3-116)
............................................
...........e)d, 3009
n..............Faith Short Hall 00,100-102,117-126)......................................ext.3010
..............Love 1(#201-215)......................................................................ext.3024
..............Love/1(#217-239)....."...'...I......................................................ext. 3025
..............Chris Ward, LPN................................................. ....ext,3012
(Person Care Administrator), (Hope,Peace and Creekside Apt.)
Pharmacy: R..............Continuing Care W............... ................ ...................1-800-675-2279
Social Services: R. ............Erin Naylor, MSW.............. ........ ............................ext.3084
(Director of Social Services)
.............Ellen Myers, BSW............................... ................ ................. ext.3023
(Social Worker)
Therapy Dept.: ❑..............Genesis Rehabilitation Seri4ces.................................. ..........ext. 3017
Volunteer Office: ❑..............Linda Waggoner................................ ....................................ext.3028
(Director of Volunteers)
Physician: 4ui_�j—Wi T7!5--:-, Telephone#: CN4-
55
Checklist—Nursing Care
1. COMPLETE/COPY:
[;�96VANCED DIRECTIVES 61J ❑LONG-TERM CARE INSURANCE POLICY
❑AMBULANCE CARD ❑PACE CARD
i r[rAPPLICATION 4 TWE F ATTORNEY
Q CHURCH OF GO HOME, INC. I �1CIAL
j ❑GENERIC EDICAL
❑ FACE SHEET ��ECURITY CARD
❑ INSURANCE CARDS VERIFIED CCINE INFORMATION FORM
❑MEDICARE ❑OTHER
❑
SUPPLEMENTAL ff` ❑COPY TO BUSINESS OFFICE
17 RX ❑COPIES TO DEPARTMENTS
i ❑OTHER ❑ COPY TO RESIDENT
❑ COPY TO RESPONSIBLE PARTY
2. REVIEW AND INFORM:
ADMISSION AND CARE AGREEMENT PHARMACY AGREEMENT
ADMISSIONS POLICY E I PODIATRY
ADVANCE DIRECTIVE POLICY E I PRIVACY ACT STATEMENT
i AMBULANCE E I PRIVATE ROOM POLICY
CHART OF COSTS E I PSYCHIATRIST
COMPLAINT PROCEDURE RESIDENT/FAMILY GUIDE
f DELEGATION FORM RESPIRATORY CARE
❑ DEPLETED FUNDS SMOKING POLICY !
❑ DIETARY SERVICES SPECIALIZED SERVICES
❑ DVD ACKNOWLEDGEMENT ❑SPOUSAL RESOURCE ASSESSMENT
❑ GUEST ROOM THERAPY SERVICES
❑ LEGAL RIGHTS COMPLIANCE E I TRANSPORTATION
❑ MEDICAID UNDERSTANDING RESTRAINT USE
MEDICARE E I VALUABLES
MISSIONNISION STATEMENT WELCOME DIRECTORY
NON-DISCRIMINATION STATEMENT F I WELCOME LETTER
PERSONAL CASH ACCOUNT E I X-RAY
I PERSONALLAUNDRY EP OTHER
I
I acknowledged that I have received the above information and_ ve beenaftrded the opportunity to ask
questions.
(Date) ( identl espons Pa
l� 1 fV
(Resident am }
f (F lity epr ntatve)
56
Ronny R Anderson
Sheriff
Jody S Smith
Chief Deputy
Richard W Stewart
Solicitor
SHERIFF'S OFFICE OF CUMBERLAND COUNTY
(..:,,FFME QF" 14E RIF
:-!LED-OFFICE
f F1C+E
OF THE PROTHONOTARY
2014 OCT 24 PM 3: 35
CUMBERLAND COUNTY
PENNSYLVANIA
Church of God Home, Inc.
vs.
Vernadeen E Junkins (et al.)
Case Number
2014-5694
SHERIFF'S RETURN OF SERVICE
09/26/2014 Sheriff Ronny R Anderson, being duly sworn according to law, states he made diligent search and inquiry
for the within named Defendant to wit: Michael E Junkins P.O.A. for Vernadeen Junkins, but was unable
to locate the Defendant in the Sheriffs bailiwick. The Sheriff therefore deputizes the Sheriff of York,
Pennsylvania to serve the within Complaint & Notice according to law.
09/26/2014 Sheriff Ronny R Anderson, being duly sworn according to law, states he made diligent search and inquiry
for the within named Defendant to wit: Barry L Junkins, but was unable to locate the Defendant in the
Sheriffs bailiwick. The Sheriff therefore deputizes the Sheriff of York, Pennsylvania to serve the within
Complaint & Notice according to law.
10/02/2014 09:08 AM - The requested Complaint & Notice served by the Sheriff of York County upon Barry L Junkins,
personally, at 24 Whiskey Spring Road, Dillsburg, PA 17019. Richard P. Keuerleber, Sheriff, Return of
Service attached to and made part of the within record.
10/06/2014 01:09 PM - The requested Complaint & Notice served by the Sheriff of York County upon Cindy Junkins,
who accepted for Michael E Junkins P.O.A. for Vernadeen Junkins, at 230 N. Grantham Road, Dillsburg,
PA 17019. Richard P. Keuerleber, Sheriff, Return of Service attached to and made part of the within
record.
10/07/2014 Sheriff Ronny R Anderson, being duly sworn according to law, states he made diligent search and inquiry
for the within named Defendant to wit: Vernadeen E Junkins, but was unable to locate the Defendant in
his bailiwick. The Sheriff therefore returns the within requested Complaint & Notice as "Not Served" at
Church of God Home at 801 North Hanover Street, Carlisel, PA 17013. Deputies were advised by the
Nursing Home Staff that the defendant was not competent and would not understand what she is being
served with.
SHERIFF COST: $76.27 SO ANSWERS,
October 22, 2014
(c} Coun.ySuiro Sheriff, Te eosoft, hoc
RONZ ANDERSON, SHERIFF
Richard P Keuerleber
Sheriff
Michael S. Hose
Chief Deputy, Operations
SHERIFF'S OFFICE OF YORK COUNTY
PETER J. MANGAN, ESQ.
Solicitor
Richard E Rice, II
Chief Deputy, Administration
CHURCH OF GOD HOME, INC.
vs. Case Number
VERNADEEN E. JUNKINS (et al.) 14-5694 CIVIL
SHERIFF'S RETURN OF SERVICE
10/02/2014 09:08 AM - DEPUTY MICHAEL DONOVAN, BEING DULY SWORN ACCORDING TO LAW, SERVED
THE REQUESTED COMPLAINT IN CIVIL ACTION (CICA) BY"PERSONALLY" HANDINGATRUE
COPY TO A PERSON REPRESENTING THEMSELVES TO BE THE DEFENDANT, TO WIT: BARRY L.
JUNKINS AT 24 WHISKEY SPRING ROAD, DILLSBURG, PA 17019.
MICHAEL CiONOVAN DEPUTY
10/06/2014 01:09 PM - DEPUTY MICHAEL DONOVAN, BEING DULY SWORN ACCORDING TO LAW, SERVED
THE REQUESTED COMPLAINT IN CIVIL ACTION (CICA) BY HANDING A TRUE COPY TOA PERSON
REPRESENTING THEMSELVES TO BE CINDY JUNKINS, SPOUSE, WHO ACCEPTED AS "ADULT
PERSON IN CHARGE" FOR MICHAEL E. JUNKINS AT 230 NORTH GRANTHAM ROAD, DILLSBURG,
PA 17019.
SHERIFF COST: $102.88
October 09, 2014
MICHAEL QONOVAN DEPUTY
SO - ERS,
RICHARD ' KEUERLEBER, SHERIFF
COMMONWEALTH 6F PENNSYLVANIA
Notarial Seal
Sheila E. Cook, Notary Public
City of York, York County
My Commission Expires Feb. 1, 2017
MEMBER, PENNSYLVANIA ASSOCIATION OF NOTARIES
Affirmed and subscribed to before me this
9TH day of OCTOBER
NOTARY
2014
(c) CounlySuite Sheriff, Teleosoft, Inc.
CHURCH OF GOD HOME, INC., : IN THE COURT OF COMMON PLEAS OF
Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA
v. DOCKET NO.: 14-5694
VERNADEEN E. JUNKINS,
MICHAEL E. JUNKINS and
BARRY L. JUNKINS,
Defendant :
CIVIL ACTION — LAW
PRAECIPE FOR ENTRY OF APPEARANCE
TO THE PROTHONOTARY:
Kindly enter my appearance on behalf of the Defendant's, Vernadeen E.
Junkins, Michael E. Junkins, and Barry L. Junkins, in the above -captioned matter.
Date:
Respectfully Submitted,
SAIDIS, SULLIVAN & ROGERS
Pearl E. -ynosa, Esquire
Attorney ID #,50440
26 West High Street
Carlisle, PA 17013
(717) 243-6222
C)
CHURCH OF GOD HOME, INC., : IN THE COURT OF COMMON PLEAS OF
Plaintiff : CUMBERLAND COUNTY, PENNSYLVANIA
v. DOCKET NO.: 14-5694
VERNADEEN E. JUNKINS,
MICHAEL E. JUNKINS and
BARRY L. JUNKINS,
Defendant
CIVIL ACTION - LAW
CERTIFICATE OF SERVICE
AND NOW, November �� ; 2014, I, Dean E. Reynosa, Esquire, hereby
certify that I did serve a true and correct copy of the Praecipe for Entry of Appearance
upon counsel of record by depositing, or causing to be deposited, same in the U.S.
mail, postage prepaid, at Carlisle, Pennsylvania, addressed as follows:
By First -Class Mail:
Brian K. Zeliner, Esquire
Hynum Law
2608 North 3rd Street
Harrisburg, PA 17110
Date: -0?�r�
ynosa, Esquire
Saidis, Sulli pan & Rogers
Attorney ID #80440
26 West High Street
Carlisle, PA 17013
(717) 243-6222
Attorney for Defendant's