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HomeMy WebLinkAbout05-2981 o SHIPPENSBURGI SOUTHAMPTON MANOR, L.P., Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v. NO. 2005- d9~ I CIVIL TERM ROBERT D. CRESSY and through his guardian, Patricia W. Cressy and PATRICIA W. CRESSY Defendants CIVIL ACTION-LA W NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an 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 LA WYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAYBE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 SHIPPENSBURGI SOUTHAMPTON MANOR, L.P., Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v. NO. 2005- ;( 'i'i1 CIVIL TERM ROBERT D. CRESSY and through his guardian, Patricia W. Cressy and PATRICIA W. CRESSY Defendants CIVIL ACTION-LA W COMPLAINT NOW, comes ShippensburgfSouthampton Manor, L.P., ("Shippensburg Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets forth the following: I. Shippensburg Health is a Maryland Limited Partnership duly authorized to conduct business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257. 2. Defendant, Robert D. Cressy, is an adult individual with a residence address of 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257. 3. Defendant, Patricia W. Cressy, is an adult individual with a residence address of 140 Green Leaf Road, Chambersburg, Franklin County, Pennsylvania 17201. 4. Patricia W. Cressy is the guardian for Robert D. Cressy, as to his person and his estate, by virtue ofan Order issued by Judge Walsh in the Court of Common Pleas of the 39th Judicial District, Franklin County Branch, Orphans' Court Division No. 61 of2004. A true and correct copy of the Order is attached hereto as Exhibit "A." I 5. Shippensburg Health owns and operates a skilled nursing facility located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania ("facility"). 6. On or about November 8, 2004, Patricia W. Cressy sought to have Robert D. Cressy admitted to the Shippensburg Health facility. 7. In connection with seeking admission, Patricia W. Cressy met with Shippensburg Health employees at the facility and executed an Admission Agreement by and through her authority as the guardian of Robert D. Cressy. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "B" and is incorporated by reference. 8. Robert D. Cressy became a resident of the facility on November 8, 2004 and remains a resident to the date hereof. 9. Pursuant to the Admission Agreement, Robert D. Cressy agreed to pay from his own funds any costs of care not covered by a third party payor. 10. Pursuant to the Admission Agreement, Patricia W. Cressy agreed to pay from the income and assets of Robert D. Cressy any costs of care not covered by a third party payor. II. The Admission Agreement provides, in relevant part, as follows: Penalties We may not charge you interest if you pay your bill in time. Your payment is on time if it is made within forty-five (45) days of the date the bill is post marked, or thirty (30) days after the end of the billing period, whichever is later. The penalty we charge iffive (5%) percent of the amount due, calculated on a per day basis. If you or your representative do not pay the money you owe us and we hire a collection agency or attorney, you agree to be liable for their fees and court costs. 2 12. A true and correct Statement of Account reflecting the balance due ManorCare for the costs of care provided to Robert D. Cressy is attached hereto as Exhibit "c" and is incorporated by reference. COUNT I-BREACH OF CONTRACT HCR MANORCARE, INC. v. ROBERT D. CRESSY AND PATRICIA W. CRESSY 13. Plaintiff incorporates by reference paragraphs one through twelve as though set forth at length. 14. All conditions precedent to recovery under the Admission Agreement have been fulfilled. 15. Patricia W. Cressy was obligated to use the assets and income of Robert D. Cressy to satisfY the debt due and owing to Shippensburg Health for the services and care provided to Robert D. Cressy by Shippensburg Health. 16. The amount due and owing is not covered by a third party payor. 17. Patricia W. Cressy has breached the Admission Agreement by failing and refusing to pay for the service and care provided from the assets and income of Robert D. Cressy. 18. Robert D. Cressy has breached the Admission Agreement by failing and refusing to pay for the service and care provided to him by Shippensburg Health. WHEREFORE, Plaintiff requests judgment in its favor and against the Defendants for the sum of $25,408.00 plus late fees, interest, costs and expenses, attorney fees and any other amount coming due to the date of award. 3 COUNT III-SUPPORT HCR MANORCARE v. PATRICIA W. CRESSY 19. Plaintiff incorporates by reference paragraphs one through nineteen as though set forth at length. 20. Patricia W. Cressy has been and is the wife of Robert D. Cressy at all times relevant hereto. 21. Upon information and belief, Patricia W. Cressy has been and is of sufficient financial ability to financially assist Robert D. Cressy in meeting the costs of his care. 22. Robert D. Cressy, as a consequence of his failure to pay the amounts due and owing for his care, is indigent. 23. Pennsylvania statutes permit a court to direct the spouse of an indigent person to financially assist such indigent. 62 P.S. 91973. 24. The care and services provided by Shippensburg Health to Robert D. Cressy are necessaries. 25. A creditor who has provided necessaries for the support or maintenance of a person may institute suit against that person's spouse for the price of said necessaries. 23 Pa. C.S.A. 94102. 4 ~ 8ne,u~ iN, {';eer->9 WHEREFORE, Plaintiff requests judgment in its favor and agains~ in the amount of $25,408.00 plus interest, costs and expenses. Respectfully submitted, O'BRillN, BARJe & s:~ ~/ad David A. Baric, Esquire J.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 2249-6873 Attorney for Plaintiff dab.dirlshcc/cressy/complaint.pld 05/07/2005 15:04 7172495755 DES PAGE 08 VERIJ!'ICATIQ.N The statements in the foregoing Complaint are based upon information which has been a5sembled by my attorney in this litigation. The language of the statements is not my own. I have read thc statements; and to the extent that they are based upon information which I have given to my counsel, they are true and correct to the best of my knowledge, information and belief. I understand that false statements herein are made subject to the penaltics of 18 Pa.C.S. ~ 4904 relating to unsworn falsifications to authorities. DATE: &ju!0 '~:.:{~i;~fi~~~i:~f.t{i.;'t;~~~7;~r~;~@;~:~~J1;~,g;1!,JiemtQ~:r1:~~1~~~*tX~{~~"ft~iS~{{,~~D~ On April 16, 2004, Patricia W. Cressy filed in the Orphans' Court Division her Petition to Adjudicate Incapacity of Robert D. Cressy and Appointment of Guardian of His Person and Estate. Patricia is Robert's wife. By Preliminary Decree the matter was set do\Vn for hearing on May 26, 2004; Philip Levine, Esq. was appointed by the Court as counsel for Robert during the proceedings; and Robert was timely served and read a Citation with Notice. Hearing was, in fact, held on May 26, 2004 at which the Court heard from Patricia and from Dr. Sajay Dhar, Robert's attending physician. Based upon the evidence we heard, we make the following: FINDINGS OF FACT 1. Family, par'.ies and v.,itnesses attending the heariJig were Petitioner, Patricia W. Cressy, and Attorney Philip Levine. Kat present were Robert Cressy's children, each of whom had been served notice of the time and date of the hearing. The court heard testimony from Dr. Sajay Dhar, via sworn telephocic testimony, and P atricia" "'V. Cressy, ffi person. RCCc:1 D. C:-essy is c'..::l:er:::y a r~s:':.e::'I of the ~ranorCa:e );ll:'3mg Home: C.c.2.20ersotrrg~ Fp....~-~~~ CO:..:.:J.ty, P=:::::..s:~'lva:::J., a:::.d. Dr. D:.2.! is R00er: D. Cressy's treating physician freD abot.:: ~rarch 10,2004 throu::" the present. Dr. -.,_:-._~"",_.~ ':!o: --~ 'I'?"'" ....'~::""'o;,1 ::;, ~ ~ ~ - i" .""" I ~:I.j= i ~ ~ '7 .. '-. .,: 'A't" 1~ 1 ' a x:....o.. ......~w'1 ."", EXHIBIT "A" .----- n Re: Per-son of Robert D. Cressy Jpinion No. 61 of2004 Page 2 Dhar testified that Robert D. Cressy suffers residual deficits following a closed head injury creating a condition that totally impairs his capacity to receive and evaluate information effectively and to make and CO=umcate informed decisions concerning the management of his financial affairs or to meet essential requirements for his physical health and safety. It was the opinion of the Doctor that Robert D. Cressy's injury would continue and he will not recover capacity in . the short term and currently needs plenary guardianship. Robert D. Cressy also suffered a subdural h=atoma, and has both diabetes and hypertension. 3. No other Guardian has been appointed for the estate or person of Robert D. Cressy in this or any other jurisdiction. 4. Petitioner was not aware of any health care directives executed by Robert D. Cressy. 5. Robert D. Cressy is likely to need nursing home care for the balance of his life. CONCLUSIONS OF LAW 1. Robert D. Cressy is in need of a plenary guardian o fills person and his estate. 2. Robert D. Cressy's guardianships shall be of permanent duration. 3. The foregoing conclusions are based on clear and convincing medical evidence that Robert D. Cressy ",ill experience very minimal, if any, improvement in his ability to understand information and to make and CO=umcate decisions regardi:J.g either his personal or funcial needs. . . -In Re: PersOn of Robert D. Cressy' No. 61 of 2004 Decree Nisi Page 3 F. Patricia W. Cressy as the "community spo"use" may'receive assets and/or income and to receive the appropriate Minimum Monthly Maintenance Needs Allowance as "community spouse" so as not to become impoverished. Hurlv v. Houston, U.S.D.C. E.PA No. 93-3666; and Department of Public Welfare Rules and Regulations. ' G. The Guardian is authorized to pay privately for Robert's nursing home care, if required, until such time as Robert would become Medicaid eligible. H. The Guardian may appeal any denial of Medical Assistance and enter into any stipulated agreement( s) with the Department of Public Welfare on behalf of Mrs. Cressy, individually and Robert D. Cressy, consistent with then. existing law, and Department of Public Welfare Rilles and Regulations. 1. The Guardian is authorized to confum that any funeral home and burial costs is or shall be irrevocably transferred to a funeral home as required by the PeIllJSylvania Department of Public Welfare Rules and Regulations. J. In the event Patricia W. Cressy shall predecease her husband, any successor Guardian is authorized to "elect against the electable estate" of Patricia W. Cressy on behalf of Robert Cressy as authorized by 20 Pa. C.S.A. 2203 et. seq. 5. The Guardian shall file an inventory within ninety (90) days of the date this Decree becomes final; and pursuant to 20 Pa.C.S.A. 95521(c),'a report by the Guardian shall be filed within twelve (12) months of this Order of Court and annually thereafter. 6. Robert D. Cressy, was not present at the hearing. Therefore, Petitioner shall serve upon and read to Robert D. Cressy a copy of this Decree and a statement of Robert D. Cressy's rights, and Petitioner shall file proof of such service ",ith the court ,-,ithin ten (10) days of me date oftbis Decree. 7. Petitioner's counsel fees incident to the mardianshiu hearincr and the " . " i.2pl=entation of this order 0: cour: am'. expe~es of Robert D. Cressy's Medicaid .' In Re: Person of Robert D. Cressy Decree Nisi. No. 61 of 2004 Page 4 application will be paid by Patricia W: Cressy as' part of an anticipated Medicaid "spend down". 8. Patricia W. Cressy shall pay counsel fees for Philip Levine, Esquire in the sum of $605.00 as part of an anticipated Medicaid "spend down". 9. Robert D. Cressy, an incapacitated person, individually or through his Court- appointed attorney has the right to appealffile objections to/except to this Decree Nisi within ten (10) days after service hereof or to petition this Court for a review hearing to modify or terminate the guardianship at any time. 10. The aforementioned judicial determinations have taken into consideration the matters required by 20 Pa. C.S.A. 95521.1. 11. The Clerk of Courts shall mail a copy of this Decree Nisi shall to R. Thomas Murphy, Esquire and Philip Levine, Esquire, counsel of record for the parties. The parties hereto shall have ten (10) days after service by the Clerk of Courts to file objections to the proposed Order of Court. Pursuant to the authority of Rule of Civil Procedure 237. 1 (b)(l), in the event no objections are timely filed hereto, this Decree shall become a final Order of Court. By the Court, +~~~H CARE CENTER 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257-9005 (717) 530-8300 FAX (717) 530-8304 TTY 1-800-654-5984 ADMISSION AGREEMENT This Agreement is between Shippensburg Health Care Center (the "Facility" or "we" and) l./l'ba-r Q r~~S-r (the "Resident" or "you") and, if you or the court have designated an individual to act on your behalf, or there is another individual to act on your behalf, or operation oflaw, -TA-lt\ (.1 k W. CWss-f ("your representative"). A checklist of the rights and responsibilities applicable to your representative is listed in Exhibit 1 and is incorporated into this Agreement. P:lvinl!' for Your Care If you are applying to this facility as a private-pay resident, you must provide all financial infOlmation requested by us. If we later find that the infomlation you or your representative provided was incomplete or inaccurate; we will consider that as a breach of this Agreement which gives us the right to pursue all legal remedies against you or your representative Who Can Be Reauired to Pav for Your Care Only you and your insurer can be required to pay for your care. No other DersOll, (i.e. a family member. tTiend, neighbor, legal representative or guardian) can be required to pay from their own funds for your care, although he or she may knowingly and voluntarily agree to guarantee payment for the cost of your care. We require the person responsible for making payments on your behalf to pay for your care under the tenus of this contract in a timely manner. If you are a beneficiary of Medicare, Medicaid or any other third-party payment plan, your representative agrees to make all necessary payments from your funds. Your representative could face a civil penalty for intentionally failing to pay required amounts from your funds and could face a criminal penalty for abusing your funds. Private Pav Residents The items and services included in our daily rate is basic room, board and general nursing care as required by your medical condition. Payment for items and services that are included in the daily rate and is payable one month in advance and due on the first of each month. Items and services included in your daily rate are listed in Exhibit 2.A. You will be charged separately for additional items and services not included in our daily rates such as special nursing care, special equipment, phanuacy charges, laboratory charges, medical transportation and additional services such as telephone expense, dry cleaning, beauty and barber services and newspapers Items and services for which you will be charged are listed in Exhibit 2 B. Payment for these additional items and services are due after you have requested them, and: you have received and have been billed for them. Within 30 days of receiving an item or service, EXHIBIT "B" you have the right to ask us for an itemized financial statemer:c that briefly but clearly describes each item and the amount charged for it. You will be given an updated listing of services and related charges, including any charges for services not coyered under Medicare or by the facilities basic per diem charges, annually on or about January 1 of each year. Medicare Residents We participate in the Medicare Program. Medicare may pay for some or all of your nursing home care. For information on Medicare, see Exhibit 3. If you are eligible for Medicare, you have the right to have claims for your nursing home care submited to Medicare. Medicaid Residents We participate in the Medicaid program. For information on \cIedicaid, see Exhibit 3. You are not required to give up any of your rights to Medicaid benefits to be admitted or to stay here. If your private funds are used up during your stay here and you are eligible for Medicaid; we will accept Medicaid payments although Medicaid may require you to pay some amount in addition to what Medicaid pays for your care. If you are planning en applying to Medical Assistance later, you may want to find out now if your are "medically eigible" for nursing home payment by Medicaid. You are responsible for applying for and obtaining Medicaid benefits and we will assist you. We may not charge, ask for, accept or receive any gift, money, denation or consideration other than Medicaid reimbursement as a condition of your admission 0, continued stay here except that Medicaid may require you to pay certain amounts from your pC-:vate funds. If you receive Medicaid, most of your nursing home charges such as room, board, and general nursing care are covered. For a list of services covered by Medicaid, see Exhibit 4.A. The local Board of Assistance will tell you whether you have to pay parr of the charge for your care and, if so, how much. Some of the items and services that we offer are not covered by Medicaid. If you want any items or services, which are not covered by Medieid, you or your representative will have to pay for them. A list of the items and services not cm'ered by Medicaid and the charges for them are in Exhibit 4.B. Payment for items and services tJat are not covered by Medicaid is due after you have requested them, and; have received and ha';e been billed for them. Within 30 days of receiving the item or service, you have the right to ask us for an itemized statement that briefly but clearly describes each item and the amount charged lor it. Increases in Charl!es and Fees Any time we increase a fee or charge for item or service or !dd a new item or service, we will provide you and your representative with 30 days advance wrir:en notice. Penalties We may not charge you interest if you pay your bill in time. Your payment is on time if it is made within 45 days of the date the bill is post marked, or :0 days after the end of the billing period, whichever is later. The penalty we charge is 5% of tl:e amount due, calculated on a per day basis. If you or your representative do not pay the money you owe us and we hire a collection agency or attorney, you agree to be liable for their fees and court costs. Private Duty Nurses Geriatric Aides If you want a private duty nurse or a private duty geriatric aide, you are responsible for selecting a person licensed and/or certified according to Pennsylvania laws and regulations. You are also responsible for paying him or her and for letting us know that you have hired one. The person you hire is not an employee or agent of the facility, but he or she must meet our standards and follow our policies and procedures. Employees of the Facility may not serve as private duty nurses or private duty geriatric aides. Boldin\! Your Bed if You Leave the Facility If you are hospitalized or on leave from the Facility, we will hold your bed for you as follows: A. If you are private-pay resident, or are receiving inpatient care reimbursed under Medicare Program (and you are not covered under Medicaid), unless you notify us otherwise, we will hold your bed for as long as you pay for it at the daily rate you are currently being charged. B. If Medicaid pays for part or all of your nursing home care and you need to be hospitalized, we will hold your bed for up to the maximum number of days required by this state, currently 15 days. If you leave for any other reason, we will hold your bed for up to the maximum number of days required by this state, currently 18 days. You have a right to be readmitted to the facility to the first available appropriate bed. While we are holding your bed, you are still required to pay the Facility any amount for which you are liable as determined by the Medicaid Program. c. If you have applied for Medicaid, your bed will be reserved in accordance with Paragraph B. However, if you are found to be ineligible for Medicaid, then you are required to pay for the bed as a private pay resident as described in Paragraph A. D. Other third-party payers mayor may not have a bed hold policy. We will discuss this if it applies to you. Your Ri\!ht to Make ComDlaints and Su\!\!est Chan\!es in Policies and Services As a nursing home resident, you have many rights according to State and Federal law. These are described in detail in Exhibit 6, which is attached and is part of this Contract. You may make complaints about your care in the Facility and you may also suggest changes in the policies and services of the Facility. You will not be harassed or discriminated against for making a complaint or suggesting a change in a policy or service. You may present your complaints to facility, management company or to one of the following State agencies: Larry D. Cottle, LNHA Administrator Shippensburg Health Care Center 121 Walnut Bottom Road Shippensburg, P A 17257 717-530-8300 Peter E. Perini, Sr. President Magnolia Management, Inc. 1710 Underpass Way Hagerstown, MD 21740 301-745-8700 Ombudsman Office of Aging 16 West High Street Carlisle, PA 17013 717-240-6110 717-532-7286 Ext. 6110 Department of Health 100 North Cameron Street 2nd Floor Harrisburg, PA 17101 717-783-3790 Your Ri2:ht to Make Decisions You have the right to make your own medical decisions and to manage your personal affairs. If you become disabled, it may be necessary for someone else to make decisions for you. For this reason, we recommend that you have a living will and/or advance directive for medical decisions and a financial Power of Attorney but you are not required to do so. See Exhibit 7 for a description of your legal rights to decide about your future medical treatment. Transfer. Relocation and Discharl!:e You have the right to remain here, and you may not be transferred, relocated or discharged against your will, except for the following reasons: (I) A medical reason (i.e. the facility cannot provide the kind of care that you need, your condition has improved so that you no longer need the care we provide, or a medical emergency arises; (2) Your welfare or the welfare of other residents or staff; (3) Nonpayment for a stay, or (4) the Facility ceases to operate. If we decide that you should be transferred or discharged, we will notifY you, and an immediate family member or legal representative, by letter 30 days in advance. If you are transferred because of an emergency situation, we will provide the required notice as soon as practicable. The letter will contain the reasons for the transfer or discharge and its effective date. The letter will also tell you how you can appeal our decision to transfer or discharge you. If you are discharged involuntarily, we will attempt to make other appropriate arrangements for your care. However, if other arrangements are not available, your representative agrees to accept you into his or her custody if it is medically appropriate. Your Ril!:ht to End This Contract If you decide to end this Contract and leave the Facility, you must pay your bill before you leave. You must give us five (5) days written notice to terminate this contract. If you leave before the end of that time, you must still pay for each day of the required notice. In the event you die while a resident of the facility, your representative is responsible for making the funeral arrangements. We will notifY your representative immediately. If we are unable to reach your representative, we will contact the funeral home of your choice to facilitate arrangements. Additional Documents It is not possible to cover everything that is important to your stay in our Facility in the body of this Contract. Therefore, we have included additional important documents as Exhibits. These Exhibits are part of this Contract. Please verifY that you received the Exhibits and that the contents of the Exhibits were explained to you by placing your initials on the line next to the description of each Exhibit. ~xhibit 1. Rights and Obligations of Representatives. ~ Exhibit 2. For Private Pay Residents: ~ (a) Items and services covered by daily rate. (b) Items and services not covered by daily rate. ~xhibit 3. How to Apply For and Use Medicare and Medicaid Benefits. xhibit 4. (a) Items and Services Covered by Medicaid. (c) Items and Services Not Covered by Medicaid. 'bit 5. Physicians Who Practice at the Facility. Exhibit 6. Legal Rights of Pennsylvania to Decide Future Medical Treatment. Policies and Procedures Concerning Your Personal Funds and Your Personal Property. ~bit 8. Services Provided by Outside Health Care Providers. Chanl!'es in Law Any provision of this Contract that is found to be invalid or unenforceable as a result of a change in S tate or F ederallaw will not invalidate the remaining provisions of this Contract. If there are services we have agreed to provide that are later found to be impossible to render as a result of a change in State or Federal law, it is agreed that to the extent possible, the Resident and the Facility will continue to fulfill our respective obligations under this Contract consistent with the law. ~TNESS WHEREOF, the parties have executed this Contract on this J.!!::day of 16NJ~6lL- , 71'\1'9 t./ . Witness By: Larry D. Cottle, Administrator Shippensburg Health Care Center Witness Resident If the Resident has been adjudicated disabled or the Resident's doctor determines that the Resident is incapable of understanding or exercising his or her rights and responsibilities, the Facility may require the signature of another person on this contract. The other p~e: (1) An appointed healthcare agent under an advance directive for medical care; (2) ardia or Power of Attorney 0 he person; (3) A surrogate or family member. ~~ [2-) Title: Indicate whether you are (I), (2) or (3) .n 2 20,'; 3, l' ell , "" '.) ~ , .J I I .VI S~;P::\;Sc;G l:A_T~ CARE CTR No. 3343 2 EXHIBIT 1 RIGHTS AND OBLIGATIONS OF REPRESENTATIVE - The-Representative shall,have the right to be notified by the Facility orany'event or, occurrence .," . involving the Resident,:which'direct1y affec18 'anyobligation' of.the,Representative'under. this ." , , 'Agreemenb<:'+Representative agrees to-assume--independently, "under..thiS>1Agreemen~ the followingl, obligationsand"is entitled to thefollowmg. rights/as indicated>'by.~epresentative1s . initials aceompanying any of the fopowmg provisions: .. - Representative. agrees to be' responsible for ensuring. that. an}'i'Paymeilt".fr6lft t:he"resident to.. which. the Facility is. entitled. pursuant to. this Agreement sha.lhbe:,paid,.t0.the~Baeility in. a timely maimer. In the event the Resident is a beneficiary of Medicare, Medicaid or any other third~party payment plllD; Representative agrees to ensure that all co-payments, co-insurance or charges and fees for non-covered items and services, together with any late fees as . descnoed. under this Agreement,. shall be paid from the Resident's funds... . Rep~ntative is ." - . subject' to 'a'cM! 'penalty for wiIlfuJ . violation' of the"agreement,.-(o.>diStribtrte'1he'Resident's funds to the facility. · (Unless.the RepresetrtativevoluntariIy agrees to act as guarantor), Representative shall be . . . responsible for any payments. required under' this' Agreement only . to .the' extent. of the Resident's funds. . .,. Resident, is applying. for admission on private. pay basis, and ,.Representative agrees to. assist . the Resident in. providing' all financial -infurmation required by the Facility. to determine the .' extent. of the Resident's resources. If it is ever determined the Representative parti~pated in the disclosure of incomplete ot inaccurate infurmation, the incomplete or inaccurate disclosure shall be deemed a matei-ial breach of this Agreement and the Facility reserves the riglti to pursue all available legal remedies against the Representative, including but not limited to an action for breach of contract. · Representative is signing this Agreement as a duly authorized agent such as an appointed hea.lthcare agent under an advance directive or guardian appointed by a court. A copy of all supporting documentation for this representation is attached to this Agreement. · Representative is signing this. Agreement on Resident's behalf; based upon a physician's certificate, a copy of which is attached to this Agreement, certifying that Resident does not possess the capability to understand his or her rights and responsibilities. · Representative agrees that in the event of the Resident's death, Representative shall take responsibility of all burial arrangements for the Resident and for removal of all personal property from the Facility. ,_,U~. 2. 20:J5 3:3',Jv 3~::'tN33,iG ~:AlTr CARE CTR No, 3343 p, 3 (Exhibit 1, Continued) . H it is the desire of the Resident or Representative to obtain the supplemental services of private duty nurses in accordance with the requirements described under this Agreement, 'Representative' agrees to' be responsible fol' arranging' independently for those services, including ensuring any payment. . ,Representative agfees, that in the event the Resident's private funds -afll'.eJdlausteddtirlng the ", "-' Resident~s.stay and, the: Resident is:.eligible to apply for. benefits under..theMedicaicI'Program, . the. Representative shall' assist the Resident and "the" Facility'with 'any. application for Memcaid benefits.,. Representative, furlher"agrees to. aet;/oii;behalf,oNhe\Resident," to _. ". fa.6ilitate any Medicare; , Veterans 'Administration' or other tbird:.party,benefits, which. may be available to cover the cost of Resident's care at the Facility. · . In the event the resident seeks to terminate this Agreement, the Representative agrees to ensure that all notices required under this Agreement are provided to Facility, ".. In. the event of an involuntary termination of tbis Agreement,. if.other ','arrangements acceptable to the Resident cannot be mad~ the Representative agrees to accept the. Resident into the Representative's custody, ifmedicallyappropriate. .' Representative has. the right to copies of the following docwnents and any amendment to them: 'Representative further acknowledges receipt of the following.. documents, which may be amended from tlme-to-time. 1. A copy of this Admission Agreement. 2. A list of the Facility's rates, subject to amendment on'thirty-(30) days notice, and a description of charges for services not included. 3. A list of health care providers offering services at the facility. · Representative acknowledges the Facility's right to any legal remedies available under law for Representative's breach of this Agreement. EXHIBITS TABLE OF CONTENTS Exhibit 1 Rights and Obligations of Representatives. Exhibit 2 For Private Pay Residents: A. Items and Services Covered by Daily Rate B. Items and Services Not Covered by Daily Rate. Exhibit 3 How to Apply For and Use Medicare and Medicaid Benefits. Exhibit 4 A. C. Items and Services Covered by Medicaid. Items and Services Not Covered by Medicaid. Exhibit 5 Physicians Who Practice at the Facility. Exhibit 6 Legal Rights of Pennsylvanian's to Decide About Future Medical Treatment. Exhibit 7 Policies and Procedures Concerning Your Personal Funds and Your Personal Property. Exhibit 8 Services Provided by Outside Health Care Providers. EXHIBIT 1 RIGHTS AND OBLIGATIONS OF REPRESENTATIVE . The 'Representative shall have the right to be notified by the Facility of.anyevent or. occurrence . involving the Resident, which directly affects any obligation. of the, Representative under this . Agreement.i" Representative agrees to' assume' independently,' under.' this' 'Agreement; the following', obligations and is entitled to the following. rights,: as indicated'bycRepresentative's initials accompanying any of the following provisions: · . Representative agrees to be' responsible for ensuring. that. any'payment-from'the"resident to. which the Facility is entitled, pursuant to this Agreement shall'.be,paidto,the>Faeility in, a timely maimer. In the event the Resident is a beneficiary of Medicare, Medicaid or any other third-party payment plan, Representative agrees to ensure that all co-payments, co-insurance or charges and fees for non-covered items and services, together with any late fees as . described. under this Agreement, shall be paid from the Resident's funds.. Representative is subject to' a civil 'penalty for wilIfulviolation' of the agreement 'to distribute'the'Resident's funds to the facility. · (Unless the Representative voluntarily agrees to act as guarantor), Representative shall be responsible for, any payments required under' this Agreement only to .the' extent. of the Resident's funds, .. Resident.. is applying for admission on private pay basis, and Representative agrees to. assist the Resident in providing all financial infurmation required by the Facility to determine the extent of the Resident's resources. If it is ever determined the Representative participated in the disclosure of incomplete or inaccurate information, the incomplete or inaccurate disclosure shall be deemed a material breach of this Agreement and the Facility reserves the right to pursue all available legal remedies against the Representative, including but not limited to an action for breach of contract. · Representative is signing this Agreement as a duly authorized agent such as an appointed healthcare agent under an advance directive or guardian appointed by a court. A copy of all supporting documentation for this representation is attached to this Agreement. · Representative is signing this. Agreement on Resident's behalf, based upon a physician's certificate, a copy of which is attached to this Agreement, certifying that Resident does not possess the capability to understand his or her rights and responsibilities. . Representative agrees that in the event of the Resident's death, Representative shall take responsibility of all burial arrangements for the Resident and for removal of all personal property from the Facility. (Exhibit I, Continued) · If it is the desire of the Resident or Representative to obtain the supplemental services of private duty nurses in accordance with the requirements described under this Agreement, Representative agrees to be responsible for arranging independently for those services, including ensuring any payment. · . Representative agrees, that in the event the Resident's private fundsareexbausted during the . , Residenfs,stay and the Resident is eligible to apply for benefits under,the Medicaid Program, the' Representative shall assist the Resident and the Facility, with any application for Medicaid benefits. .'. Representative. further agrees to" act; I oiLbehalfiOf,the ',Resident, , to facilitate any Medicare; , Veterans Administration, or other third"party, benefits. which may be available to cover the cost of Resident's care at the Facility. · In the event the resident seeks to terminate this Agreement, the Representative agrees to ensure that all notices required under this Agreement are provided to Facility. · In the event of an involuntary termination of this Agreement,.. if. other 'arrangements acceptable to the Resident cannot be made, the Representative agrees to accept the Resident into the Representative's custody, if medically appropriate. · . Representative has. the right to copies of the following documents and any amendment to them: Representative further acknowledges receipt of the following documents, which may be amended from time-to-time, 1. A copy of this Admission Agreement. 2, A list of the Facility's rates, subject to amendment on' thirty-(30) days notice, and a description of charges for services not included. 3. A list of health care providers offering services at the facility. · Representative acknowledges the Facility's right to any legal remedies available under law for Representative's breach of this Agreement. EXHIBIT 2.A Private Pav Residents A. Items and Services Included in the Dailv Rate The items and services included in the daily rate, and their related charges, are listed below: Descriotion of Items and Services Included in the Dailv Rate 1. Room 2. Board 3. Social Services 4. Nursing Care, including: a. The administration of prescribed medications, treatments and diets. b. The provision of care to prevent skin breakdown, bedsores and deformities. c. The provision of care necessary to encourage the resident from accident, injury and infection. d. The provision of care necessary to encourage, assist and train theresident in self-care and group activities. 5. Other: Activities Total Dailv Room Rates (effective July I, 2003) Special Care Program Private Rooms $179.00 $189.00 Semi-Private Rooms $164.00 $152.00 $184.00 Triple/Quad Rooms $174.00 Medicare co-pay: $105.00 EXHIBIT 2.B ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE The following items and services are not covered by the Facility's basic daily rate: Item or Service Physician Services Medications Prescribed Dietary Supplements Personal Dry Cleaning, Personal Linens Telephone Television Service Beauty/Barber Shop Services Clothing Sundry Pharmaceutical Ambulance Service, Medical Transportation N Therapy X-Ray Services Medical-Nursing Supplies Dental, Podiatrist and Opthamology Services Physical, Speech and Occupational Therapy Services Oxygen Newspaper, Periodicals Lab Services Specialized and/or specially ordered medical services/equipment Guest meals (Exhibit 2.B, Continued) ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE (refer to the Ancillary Charge List for additional costs) Item Charge Telephone Direct bill from telephone company Television/Cable per month $7.00 per month . Beauty/Barber Shop Services: Permanent Haircuts and Blow-dry Hair Sets Cut Only Color' $35.00 $10.25 $8.25 $8.25 $30.00 Personal Laundry $45.00 per month Personal Dry Cleaning Same as billed by cleaner Physical Therapy Service Detennined by level of care required Occupational/Speech Therapy Determined by level of care required IV Therapy Charge list will be provided by contract pharmacy prior to delivery of services Aerosol Therapy Detennined by level of care required *************************************~**************************************** Shippensburg Health Care Center cordially invites family members, guests and friends to join our Resident's at meal times. The prices for guest trays, effective July 1, 2001 are as follows: Breakfast A Breakfast B Lunch A Lunch B Dinner A Dinner B $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 Will be served at 7:00 AM ($3.77 + .23 state tax) served at 7:30 AM Will be served at 12:00 PM ($3.77 + .23 state tax) served at 12:30 PM Will be served at 5: 00 PM ($3.77 + .23 state tax) served at 5:30 PM *The Resident's will be assigned their meal times upon admission. Meals can be paid for at the Receptionists' desk. In order to prepare sufficient quantities we require a 2-hour notice to prepare guest tray. EXHIBIT 3 The following summarizes the Medicare and Medicaid programs. It also tells you who to call for more detailed infonnation. If you have questions, our staff will also help you. What's Covered - Medicare 1. Care in a hospital 2. 100 days of skilled care in a nursing home. Medicare provides full 'coverage for the first 20 days. You must make a co-payment after that. Thefollowing services are examples of skilled care: a. Injections & feedings given through an IV b. Tube feedings c. Application of a dressing that involved prescription medication d. Treatment of stage 3 or 4 bedsores 3. Medically necessary doctor's services. What's Covered - Medicaid Medicaid is a comprehensive program that will cover most of the costs'of a nursing home stay. '. See Exhibit4 for information about covered and non-covered items. Your Contribution - Medicare . Medicare does not pay 100% of the cost of covered servicevYouwill be required to pay part of the charges. Your payment may be called a "co-payment", "deductible" or ."premium", depending on the type of care provided. If you receive Medicaid, Medicaid will pay for any payment that you are responsible for under Medicare. Your Contribution - Medicaid. Depending on your income and assets, you may be required to make a contribution toward the cost of your care. The amount of any contribution will be decided by the local Board of Assistance. Who's Elie:ib"le - Medicare People 65 years old orolder-who are eligible to collect old-age benefits under Social Security are eligible. Persons who receive Social Security disability benefits for at least 24 months, or have been found eligible' for Medicare- by the Social Security Administration because they have end stage renal disease requiring regular dialysis or kidney transplant are also eligible. Who's EIie:ible ~ Medicaid . Eligibility depends on whether your income and assets are below certain levels: 1. Income: You should consult the local Board of Assistance to find out whether your income makes you eligible. That phone number is listed on the next page. If you qualifY, $30 per month of your income is protected for your personal use while in the Facility. (Exhibit 3, Continued) 2. Assets: The Cumberland County Board of Assistance will also be able to evaluate your assets and tell you whether you qualify. The following are examples of things not counted as assets. a. Your house if your spouse lives there. b. Household goods. c. A certain amount of cash. d. . Personal Property in your possession in the Nursing home. e. A certain amount of money for burial arrangements. How to Applv - Medicare Contact the local Social Security Office at the following address: Social Security Office 401 E. Louther Street Carlisle, PA 17013 (800) 772-1213 (717) 243-0085 How to Applv - Medicaid Contact the local County Board of Assistance at the following address: Board of Assistance 33 Westminister Drive Carlisle, PA 17013 (800) 269-0173 (717) 249-2929 ~" Whom to Contact if vou have a Ouestion or Problem - Medicare If Medicare denies a claim, you have the right to appeal the denial. Yau may appeal by writing to: Aetna Medicare Claim Administration 501 Office Center Building Fort Washington, PA 19034 (215) 643-7200 Whom to Contact ifvou have a Ouestion or Problem - Medicaid If your application for Medicaid is denied, your coverage is terminated, or a service is not covered, you may appeal in writing to: County Board of Assistance Office 33 Westminister Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 (Exhibit 3, Continued) Whom to Contact ifvou have Incurred Medical Exoeuses orior to vour MA Effective Date Medicare - Not applicable . ': ',Whom to, Contact ifvou have Incurred Medical Exoenses orior to.vour MA Effective Date. . , - Medicaid Medical bills that you received in the 3 months prior to' receiving Medicaid'may be'covered by Medicaid, Contact: CountyBoard of Assistance Office 33 Westminister Drive P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 EXHIBIT 4.A A. Items and Services Covered bv the Medicaid Per Diem Rate , · : Regular rooll1;uietary'services, social services and other. services required. to meet certification standards, medical and surgical supplies;' and the use of equipment and facilities. ....; General nursing 'services,' including but not.!inJ.ited to~".adrninistration:of'oxygen 'and related:; medications; handfeeding, incontinencY':~care;jf,.tray'.service' and enemas. .. Basic BeautyIBarber Services: The facility must provide' shampooing and hair care which is considered necessary for hygiene. The facility must infonu the resident of the types and frequency of the services provided. · Items furnished routinely and relatively uniformly.to all-residents, such as water pitchers, basins, and bedpans. · Items furnished, distributed, or used individually in'~.small quantities such as alcohol, applicators, cotton balls, band"aids; antacids,' aspirin (and other nonlegend drugs ordinarily kept on hand), suppositories; and tongue depressors.. · Items used by individual residents but which are reusable and' expected to be available such as ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment, and other durable medical equipment. · Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diets, even if written as a prescription item by a physician. · Laundry services for other than personal clothing. · Non-emergency.medical transportation services. · Other special medical services of a rehabilitative, restorative, or maintenance nature, designed to restore or sustain the resident's physical and social capacities. . Personal care items including a patient gown, shampoo, skin lotion, comb, brush, toothpaste, toothbrush, and denture cream. EXHIBIT 4.B B. Items and Services Not Covered bv the Medicaid Per Diem Rate . Medical expenses such as, but not limited to: . Health insurance premiums. .. Visits by a non-participating, physician. other than' approved by the. nursing care facility. . Emergency ambulance services,' if the ambulance' company does not accept'MA. · Over-the-counter medications, which are a particular brand not supplied by the nursing. facility. For example, the nursing facility must provide aspirin, but the patient may Tequest and buy a specific brand of pain reliever, such as Excedrin PM, or Tylenol. . Hearing aids and batteries. · Specialized Beauty/Barber Shop services. · . Diapers, if the resident wants a style or brandwhieh., is not, provided , by the nursing care facility. . Personal care items of the resident's choice if he prefers them instead of the items provided by the nursing care facility. This includes items such as brushes, combs, toothbrushes, cosmetics, etc. EXHIBIT 5 PHYSICIANS WHO PRACTICE AT THE FACILITY Dr. Yogindra S. Balhara, M.D. 761 Fifth Avenue Chambersburg, PA 17201 (717) 261-2583 . Dr. William Kramer, M.D. 144 South Eighth Street Chambersburg, P A 17201 (717) 264-6511 Dr. Paul Orange, M.D. 4225 Lincoln Way East Fayetteville, P A 17222 (717) 352-3616 . Dr: Baxter Drew Wellman, II, D.O.,P.C. 127 Walnut Bottom Road Shippensburg, P A 17257 (717) 532c3211 Dr. Hong S. Park, M.D. 120 North Seventh Street Chambersburg, PA 17201 (717) 267-7735 EXHIBIT 6 LEGAL RIGHTS OF PENNSYLVANIANS TO DECIDE ABOUT HEALTH CARE . . You Have the Ril!:ht to Decide About Your Health Care ". Adults,generally'havethe' right. to decide if they want medical treatment, ,"unless' they are. not .. competent.., ,This right includes decisions about treatments that'. extend life,: life"support machines" or feeding tubes. ,,,, Sometimes; . an accident . OF illness .takes away' a 'person' s abiJity;tmmake'nealtlkcarechoices; , But , . ,;the'decisions,stiIlmust be made;' Ifyou.'areunableto'make'them;'o,{)thers~w:ilIt,':The}NVilkdecide. . . based on your wishes; or your best interests if your wishes are'unknown. , Pennsylvania law gives'you the right to make many health care decisions'in advance. One way to do this is by using a written advance directive to name an agent to make your health care . decisions if you cannot. A written advance directive can also state your treatment preferences, especially about life sustaining procedures. Naminl!: a Health Care Al!:ent Yau can name' anyone to' be your health care agent. The "only,,'exception is that; , in general, someone who 'Works where you are receiving your care cannot beyour agent.' Your agent can be a family member or a mend. .. . .' Youchoose:when, your agent-can'decide for you - right away; if-.youwant; OF only after two '. doctors 'agree that you are notable.to,decide foryourselfYou'also".choose.thekinds,uf-deeisions" . your agent can'make for you.- For example, if you. want, you' can give your agent very broad power to decide about life, sustaining treatment. Pick your health care agent very carefully. Make sure your agent knows what you want. Your agent will then follow your wishes, even if your mends or family disagree. Usinl!: Advance Directives There are many ways to use an advance directive. A living will is a type of written advance directive that states your wishes on life-sustaining treatments. It usually comes into affect when a person will die very soon from an incurable condition, It can also be used when a person is permanently unconscious (in a vegetative state). You can make a broader written advance directive for other health care issues too. For example, you can decide whether you want life-sustaining treatment if you are in an end-stage condition:. An end-stage condition is an advanced, progressive, and incurable condition resulting in complete dependency. What Happens llYou Do Not Make an Advance Directive? No one can deny you health care because you do not have an advance directive. But you should know what happens legally if you do not. (Exhibit 6, Continued) Pennsylvania law allows a surrogate to make medical decisions for you if you have not named a health care agent and are no longer able to decide treatment issues yourself Then, your closest . ,relative would be asked' to' make health care' decisions' for. you. . Y our.spouse; adult. children,' '.,...' 'parents, or adult' brothers and sisters; in that order, are considered. your closest relatives. , If these' .' relatives.'are not available, another,rehitive or close fiiend ,can make, decisions for.you., .A ,.'surrogate;.though/mighthave.less' authority to" decide :againstlife'-sustaining' procedures.'than' a'. health care' agent. . . ~ 'If there is no one to be a surrogate, 'a' court. might haveto:,'appoint.a'guardian'to:.makeyour' .' ',medical decisions.. The guardian, might be somebody who doesmot..know"you'personally-.-. ,,:' '. How DoYon Get More Information? This summary. does not cover every issue.' If you have legal questions about your rights, please speak,to a lawyer., Also talk: to your health care provider aboutthe'medical,issues involved in ..' ,"':"';.Y1JUf;,Care'; TelLthose'caring for you about your 'decisions' anlligivethem,'a'copy;,(Jf'an.y:advance ., directive, For a free copy of a Living Will or Advance Directive form contact: State Representative Jeff Coy 39 West King Street Shippensburg; P A 17257 (717) 532-1707 or Cumberland County Office of Aging Human Service Building 16 West High Street Carlisle, P A 17013 (717) 532-7286Ext. 6110 (717) 240-611 0 EXHIBIT 7 POLICIES AND PROCEDURES CONCERNING YOUR PERSONAL FUNDS AND YOUR PERSONAL PROPERTY A Your Rights: 1. . You have the right to ,keep and use your-'personal:.property,-including some furnishings and clothing, so long as there is enough'spac~ and ,other residents' are not inconvenienced. . You also have the right. to security . for your'personal posseSSIOns. 2' '" :,y Oil" have'the' rightto;manageyour financiahaff-aiFs;;unless'a',eoumueterrnines, that you are" incapacitated ,., or' the. Social. Security~~'iAdministr:atiore.::tselects a . representative to receive Social Security funds for your use and benefit. 3. We cannot require you to deposit your personal funds. with us. You may, however, choose any person to manage your funds, including the Facility. 4, If you. decide to have us manage your persoriaHimds, you'may, withdraw'your money. that .we keep in the Facility during. the"Facility:s,business.,hoursL.; If we . have deposited any of your funds in a bank, you may obtain' those-funds within three banking days,' provided the funds have cleared. 5. If you. ,need help to' perfonn your bankingctransactions; you "; may.: give the administrator, of:, our Facility legal authority to'.access' your account. This authority. is called "representative' payee," To give the administrator this authority, you will need to complete a special form. 6. You and your personal representative have the right, during normal business hours, to inspect our written records that concern your personal funds. 7. You and your personal representative have a right to file a complaint if either of you believes that your funds, valuables or other assets have been stolen or damaged. The agencies to contact in order to make a complaint are listed below: a. The Cumberland County Office of Aging Attn: Ombudsman Human Services Building 16 West High Street Carlisle, PA 17013 (717) 532-7286 Ext, 6110 (717) 240-611 0 I (Exhibit 7, Continued) b. Cumberland County Board of Assistance 33 Westminster Drive . P.O. Box 599 Carlisle, PA 17013 (717) 249-2929 (800.) 269-0. 173 c. . The Department of Health Division of Nursing Care Facilities 100 North Cameron Street 2nd Floor Harrisburg, P A 171 0 1 (717) 783-3790 B. Our Responsibilities: . L ,': ,We, will,' providea. reasanable" amount ofsecureispace.,-J'ori)'ou.totkeep.:your . clothing and other persanal property.:' We mustinvestigateanydamage.to:'or loss of your personal property. 2. '. :." ,If you want us to manage $50:o.O:or...!ess:ofyauripers6naldlirids;'.we. will.deposit. . this: money in .a non~interestbearing account ora petty cash;fund: . J,', If^,yau"want' us to' manage mare'thalD'$5o.,Oo.'.of"youl'''personal,funds;..we.will deposit this money in an interest bearingaccountthaLis. insured by the federal government. This account will be separate from the accounts we use to operate the facility. In addition, we will credit you with all interest earned on your money. 4. We will maintain a full, complete and separate accaunting of your personal funds. We will alsO' provide you with a quarterly statement of the activity of your account. 5. If you receive. Medicaid benefits, we will notifY you if yaur account balance becomes toO' high. If you are to remain eligible far Medicaid, your account balance must be under a certain dollar limit that is established by the Federal government and changes periodically. . 6. We may not use your persanal funds to pay far an item ar service that Medicare or Medicaid covers. 7. We will maintain adequate fire and theft caverage to protect your funds and personal property that are kept at the Facility. We shall also obtain a surety bond ar otherwise assure the security af your personal funds that are deposited with the Facility. (Exhibit 7, Continued) 8. If you are discharged, there are several things we must do: a.We will ensure the return of your personal funds in ourcpossession.Ifwe have deposited your. personal funds in a bank account:;. we will' ensure that this money is made available to yoU' or your authorized -representative within 30 days. . . b, . c . If we are. your representative payee for; Social,' Security" benefits, '"'we will promptly' ask the Social Security ,Administration": to,'name a' new . representative payee and'we will transfeFyounuoneyto that. person;-. 9. In the event of your death, there are several things we must do: a. We will convey your personal funds and a final accounting of those funds to the. person in charge of administering..your:estate within.30 days. We will,inunediately notifY. any' government.agencyAhatcpaid.:for all;or..part. of your care in our Facility. That agency. shall have the right to assist us in determining what to do with your property. . b. . :Ifa' government agency did not pay' for your care;' we.will.inunediately . notifY.your representative or next ofkin.todetenuine'.whatto;do.withyour . property. c. If we have your funds, valuables or other assets, in our possession, we will hold them until' the appointed personal representative of your estate presents a copy of the certified Letters of Administration to us. All conveyance of personal funds will be by check made payable "To the Estate of...". d. We will make reasonable attempts to locate your personal representative and your heirs. If no claim is made on your funds, valuables or other assets in our possession within six weeks of your death, we will write the State Office of the Comptroller for direction. 10. If we are in possession of your funds, valuables or other assets for more than one year from the date of your transfer or discharge, we will transfer your funds, any interest on your funds, and your valuables or other assets to the State Office of the Comptroller's Office of any account(s) in your name of which we have knowledge. EXHIBIT 8 SERVICES PROVIDED BY OUTSIDE REALm CARE PROVIDERS .; Some of the services available.in the Facility, such' as pharmaoy. services; are. pro:vided by outside . . health careproviders.""'These services; and information about the providers;' appear below. . You are free to' pick your own provider or to use one of those listed below: Type of Service Physician X-Ray Services Lab Services Pharmaceutical Podiatrist. Podiatrist Provider's Name, Address and Telephone Number Dr. Yogindra Balhara 761 Fifth Avenue Chambersburg, PA 17201 (717) 264-6185 Mobil X-Ray Services The Chambersburg Hospital 112 N. Seventh Street Chambersburg, PA 17201 (717) 267-6356 The Chambersburg Hospital 112 N. Seventh Street Chambersburg, P A 1720 I (717) 267-7153 Pharmacare Route 3, Box 3-A Cumberland, MD 21502 (301) 777-1773 Dr. Peter Holdaway 1936 Scotland Avenue Chambersburg, PA 17201 (717) 264-5211 Dr. Kirk Davis, D.P.M. 60 1 Wayne Avenue Chambersburg, P A 1720 I (717) 267-2255 . Whether we have a financial Interest in . the Provider No No No No No No (Exhibit 8, Continued) Type of Service Dentist Hospital Inpatient or Emergency Room Provider's Name, Address and Telephone Number Whether we have a financial Interest in the Provider Health Drive . 928 Jaymor Road Suite C-190 . Southampton, PA 18966 (215) 942-9950 FAX (215) 942-9954 No Carlisle Hospital Chambersburg Hospital Fulton Co. Medical Center Hershey Medical Center Waynesboro Hospital No No No No No I STATEMENT SHI PPENSBURG HEALTH CARE CTR 121 WALNUT BOTTOM RD SHIPPENSBURG, PA 17257 Facility Phone: 717-530-8300 Resident: ROBERT CRESSY Statement Date: 05/19/05 Patricia Cressy 140 GREEN LEAF RD Chambersburg, PA 17201 Date Service Through Qty Description Amount Sub Total as of 04/30/05 13,843.00 Charaes 05/31/05 05/01/05 05/31/05 31 Room Charges Sub Total Balance 5,858.00 5,858.00 19,701.00 - Ancillary/Other Charaes 05/19/05 05/19/05 05/19/05 1 CABLE Sub Total Balance as of: 05/19/05 7.00 7.00 19,708.00 Proiected Prebill Charaes 06/01/05 06/01/05 06/30/05 30 Pre bill Room Charges Sub Total Total Amount Due 5,700.00 5,700.00 25,408.00 EXHIBIT "e" - ..... ~ ~ ~ ~ ~ G ~ \ ~ ~ ~. ~ ~ " ~ . ('\ ~~ f\ 0\ ~N ~~0 ~~ ~ (") S ~ I~t'; ~. ~. (" r~! ;? ~ ~ ...., C;:::;:) 1:;:::;) c.n '- c.::: :;t: I ..0 o "Tl -l I::n rl1r" -..Ill -~;C. (_~{(F) -,-":-, ~;} :) (")r"n ~:1 c":'" .}J ., -0 :1': w <.11 CJ SHERIFFIS RETURN - GARNISHEE CASE NO: 2004-02981 P COMMONWEALTH OF PENNSLYVANIA COUNTY OF CUMBERLAND SHERWIN-WILLIAMS COMPANY THE VS RUBY FRANK A ET AL And now SHAWN HARRISON ,Sheriff or Deputy Sheriff of Cumberland County of Pennsylvania, who being duly sworn according to law, at 0015:43 Hours, on the 22nd day of June , 2005, attached as herein commanded all goods, chattels, rights, debts, credits, and moneys of the within named DEFENDANT FUTRELL MATTHEW A D/B/A FUTURE PAINTING , in the hands, possession, or control of the within named Garnishee AMERICHOICE FEDERAL CREDIT UNION 433 S 18TH ST CAMP HILL, PA 17011 Cumberland County, Pennsylvania, by handing to KEN ROBINSON (LOAN CONSULTANT) personally three copies of interogatories together with 3 true and attested copies of the within WRIT OF EXECUTION and made the contents there of known to His . Sheriff's Costs: Docketing Service Affidavit Surcharge .00 .00 .00 .00 .00 .00 So answers: \r ~l~~~ R. Thomas Kline- Sheriff of Cumberland County Sworn and subscribed to before me this 1/<8 day o~ ..2b1J S A.D. (..1t' () }u,PI(.-, ~ Prot otary , By ... 06/23/2005 Sheriff SHERIFF'S RETURN - NOT FOUND CASE NO: 2005-02981 P COMMONTWEALTH OF PENNSYLVANIA COUNTY OF CUMBERLAND SHIPPENSBURG/SOUTHAMPTON MANOR VS CRESSY ROBERT D ET AL R. Thomas Kline ,Sheriff or Deputy Sheriff, who being duly sworn according to law, says, that he made a diligent search and inquiry for the within named DEFENDANT CRESSY ROBERT D but was unable to locate Him in his bailiwick. He therefore returns the COMPLAINT & NOTICE , NOT FOUND , as to the within named DEFENDANT , CRESSY ROBERT D 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 DEFENDANT IS IN A SECURED UNIT AND OUR DEPUTIES WERE NOT ALLOWED ACCESS. Sheriff's Costs: Docketing Service Not Found Surcharge Postage 18.00 32.00 5.00 10.00 1. 74 66.74 S~_~~~~--=-~ R. Thomas Kline Sheriff of Cumberland County OBRIEN BARIC SCHERER 07/18/2005 Sworn and subscribed to before me this .2 ;l~ day of (#1 .2C1JQA.D. ~uQ Prot 0 otary "fnJ:IJ " ~ SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2005-02981 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHIPPENSBURG/SOUTHAMPTON MANOR VS CRESSY ROBERT D ET AL R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: CRESSY PATRICIA W but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of FRANKLIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On July 18th , 2005 , this office was in receipt of the attached return from FRANKLIN Sheriff's Costs: Docketing Out of County Surcharge Dep Franklin Co 6.00 9.00 10.00 37.48 .00 62.48 07/18/2005 OBRIEN BARIC So ans):"",.r;5-7~ //.......' :-,c--/: ;>>:;;-~::~~/ /// _.~? R. Thomas Kline ( Sheriff of Cumberland County ./ SCHERER Sworn and subscribed to before me this ;Z<l.-J.... day of ~ nA.D. ~ Q 'hu-.n , +z;:: Prothonotary In The Court of Common Pleas of Cumberland County, Pennsylvania Shippensburg Southampton Manor LP VS. Robert D. Cressy et 91 SERVE: Patricia W. Cressy No. 05-2981 civil Now, June 14, 2005 , I, SHERIFF OF CUMBERLAND COUNTY, P A, do hereby deputize the Sheriff of Franklin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. .r~~ Sheriff of Cum her land County, PA Affidavit of Service ~-2-"3-()) ,20_, at 9:tfl.fAo'c!ock A- M.servedthe ~~~ C,t)"",,1'i upon ?A=rR~ u A W . ~;JS Y at IllD G~~ L(''-'1H= (1..() . ~Q. P4. t 77..1)/ Now, within by handing to ~k-(LLuA W. ~L~~y a ~ >N\, t'L-A-l ""' 2-- copy of the original {'.J\V\f'o..P~ and made known to t+ttA-. the contents thereof. So answers, ~.~PA: ~~~: Sbori~t W~teA Sworn ~d ~ubscri me thig;>(~ - day 0 20 oS:- '- COSTS SERVICE MILEAGE AFFIDAVIT $ RKiIord D NoQrw ..., Cltambor"';"'~' Norary Publi, My Conunissi ;o..FrankJln County 011 '<plres Jan. 29, 2007 ----- $ SHIPPENSBURGI SOUTHAMPTON MANOR, L.P., Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. NO. 2005- 298] CIVIL TERM CNIL ACTION-LAW ROBERT D. CRESSY and through his guardian, Patricia W. Cressy and PATRICIA W. CRESSY Defendants PRAECIPE TO DISCONTINUE TO THE PROTHONOTARY: Kindly mark the above-captioned action as having been settled and discontinued with prejudice. Respectfully SUbmitt.e .d, ?1 0' N,B~~:~ 1J~4/ i, .-'. '1t" David A. Bari,:, Esquire I.D. # 44853 19 West South Street Carlisle, PA 17013 (717) 249-6873 Date: January 12,2006 Attorney for Plaintiff, ShippensburgfSouth Hampton Manor II CERTIFICATE OF SERVICE I hereby certify that on January 12, 2006, I, David A. Baric, Esquire of O'Brien, Baric & Scherer, did serve a copy of the Praecipe To Discontinue, by first dass U.S. mail, postage prepaid, to the party listed below, as follows: R. Thomas Murphy, Esquire Patterson, Kiersz & Murphy, P.C. 239 East . Street 1 d' Waynesboro, pe~> i,a 17268 /}/ 3 k:: f( V'/'/p/{L cd/v David A. Baric, Esquire I I II !I !' I I I fv p'..J (r'