HomeMy WebLinkAbout05-29820
SHIPPENSBURG/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
DORINDA T. CONWAY,
KIERSTYN L. WALKER,
individually and as
attorney-in-fact for
Dorinda T. Conway,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- a ?JS
CIVIL TERM
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 LAWYER AT ONCE. IF YOU DO
NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
SHIPPENSBURG/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
DORINDA T. CONWAY,
KIERSTYN L. WALKER,
individually and as
attorney-in-fact for
Dorinda T. Conway,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- -;? 9 pa
CIVIL TERM
COMPLAINT
NOW, comes Shippensburg/South Hampton Manor Limited Partnership ("Shippensburg
Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within
Complaint and, in support thereof, sets forth the following:
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, Dorinda T. Conway, is an adult individual with a residence address of
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257.
Defendant, Kierstyn L. Walker is an adult individual with a residence address of
312 Harvest Lane, Shippensburg, Cumberland County, Pennsylvania 17257.
4. Defendant, Kierstyn L. Walker is the attorney-in-fact for Dorinda T. Conway by
and through that certain Power of Attorney dated November 10, 2004 a true and correct copy of
which is attached hereto as Exhibit "A" and is incorporated.
Shippensburg Health operates a resident skilled care nursing facility located at
121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania.
6. On or about December 6, 2004, Kierstyn L. Walker, sought to have Dorinda T.
Conway admitted to the Shippensburg Health facility.
On or about December 6, 2004, Kierstyn L. Walker executed an Admission
Agreement on behalf of Dorinda T. Conway. A true and correct copy of the Admission
Agreement is attached hereto as Exhibit "B" and is incorporated.
Pursuant to the Admission Agreement, Dorinda T. Conway would be responsible
to pay any costs of care which were not covered by a third party payer.
9. On or about December 6, 2004, Dorinda T. Conway became a resident of the
Shippensburg Health facility and remains a resident to the date hereof.
10. In February, 2005, the Cumberland County Assistance Office determined that
Dorinda T. Conway was eligible for Medical Assistance and Dorinda T. Conway would be
responsible to pay Shippensburg Health a monthly private pay portion of $561.40. A true and
correct copy of this calculation is attached hereto as Exhibit "C" and is incorporated.
11. As of June 1, 2005, Dorinda T. Conway owed Shippensburg Health the sum of
$3,712.40 for the costs of care provided by Shippensburg Health to her. A true and correct copy
of the Statement reflecting the balance due is attached hereto as Exhibit "D" and is incorporated.
Moreover, the costs and resultant balance owed continue to accrue.
12. Demand has been made upon Dorinda T. Conway to pay the amount due.
13 Upon information and belief, since December 6, 2004, Kierstyn L. Walker has
been the representative payee for Dorinda T. Conway and has been receiving social security
benefits on behalf of Dorinda T. Conway.
COUNT I-BREACH OF CONTRACT
SHIPPENSBURG HEALTH v. KIERSTYN L. WALKER
as the attorney-in fact for Dorinda T. Conway and Dorinda T. Conway
14. Plaintiff incorporates by reference paragraphs one through thirteen as though set
forth at length.
15. Dorinda T. Conway and her agent, Kierstyn L. Walker, have breached their
obligation to pay for the costs of care as provided by Shippensburg Health to Dorinda T.
Conway.
16. As a consequence of that breach, Shippensburg Health is owed the sum of
$3,712.40 to June 1, 2005 and the debt continues to accrue.
17. The accrued debt consists of the monthly private pay portion to be paid from the
social security benefits of Dorinda T. Conway. Kierstyn L. Walker has failed to pay the private
pay portion from the benefits she has received from Dorinda T. Conway.
18. The Admission Agreement provides in relevant part as follows: "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."
WHEREFORE, Plaintiff requests judgment in its favor and against Dorinda T. Conway
for the sum of $3,712.40 plus interest, costs and expenses and any additional amount coming due
to the date of award and attorney fees and costs.
COUNT II-MONEY HAD AND RECEIVED
SHIPPENSBURG HEALTH v. KIERSTYN L. WALKER
19. Plaintiff incorporates by reference paragraphs one through eighteen as though set
forth at length.
20. During the period of Dorinda T. Conway's residence at the facility, Kierstyn L.
Walker has been receiving social security benefits of Dorinda T. Conway.
21. The proper use of those funds would have been to pay the costs of care accruing
for the care of Dorinda T. Conway at Shippensburg Health.
22. At the time of receipt of those funds, Kierstyn L. Walker knew that these funds
should be paid over to Shippensburg Health for the costs of Dorinda T. Conway's care.
23. Kierstyn L. Walker gave no consideration for the funds of Dorinda T. Conway she
has received.
23. Demand has been made upon Kierstyn L. Walker to tender the funds of Dorinda
T. Conway to Shippensburg Health and she has failed and refused to do so.
WHEREFORE, Plaintiff requests judgment in its favor and against Kierstyn L. Walker
requiring her to:
a) return the subject matter in specie;
b) pay over the value if Kierstyn L. Walker has consumed the money in beneficial
use;
c) pay its value if Kierstyn L. Walker has disposed of the funds received; and
d) award costs, expenses and interest.
COUNT II-QUANTUM MERUIT
SHIPPENSBURG HEALTH v. DORINDA T. CONWAY
24. Plaintiff incorporates by reference paragraphs one through twenty-three as though
set forth at length.
25. During the period of her residency at the facility, Dorinda T. Conway has enjoyed
the benefit of care and services provided to her by Shippensburg Health.
26. Dorinda T. Conway has failed and refused to pay for the costs of her care and
services provided by Shippensburg Health.
27. Dorinda T. Conway Reed has been unjustly enriched by her use and enjoyment of
the services and care provided by Shippensburg Health without making payment therefor.
WHEREFORE, Plaintiff requests judgment in its favor and against Dorinda T. Conway
for the sum of $3,712.40 plus costs, interest and expenses.
Respectfully submitted,
EN, SARI SCHE
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
da b.dir/s hcc/con way/complaint. pld
7172495755 OBS PAGE 08
VERIFICATION
The statements in the Foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the 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 penalties of 18 Pa.C.S. §
4904 relating to unswom falsifications to authorities.
[?-
DATL;
PENNSYLVANIA DURABLE POWER OF ATTORNEY
Effective Immediately
NOTICE TO PRINCIPAL / GRANTOR:
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE
PERSON YOU DESIGNATE (YOUR "AGENT") BROAD POWERS TO
HANDLE YOUR PROPERTY, WHICH MAY INCLUDE POWERS TO
SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL
PROPERTY WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL
BY YOU.
THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR
AGENT TO EXERCISE GRANTED POWERS, BUT WHEN POWERS
ARE EXERCISED, YOUR AGENT MUST USE DUE CARE TO ACT FOR
YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF
ATTORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE
THROUGHOUT YOUR LIFETIME, EVEN AFTER YOU BECOME
INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE DURATION
OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT
ACTING ON YOUR BEHALF TERMINATES YOUR AGENT'S
AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR
AGENTS FUNDS.
A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT
FINDS YOUR AGENT IS NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF
ATTORNEY ARE EXPLAINED MORE FULLY IN 20 PA.C.S. CH. 56.
IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT
UNDERSTAND, YOU SHOULD ASK A LAWYER OF YOUR OWN
CHOOSING TO EXPLAIN IT TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I
UNDERSTAND ITS ONTENTS.
11-10-o
Signature of Principal / Grantor Date
of
EXHIBIT "A"
-I-
KNOW ALL PERSONS BY THESE PRESENTS.
3 o- C-DVIa 1 ("Principal") maintaining an address at
1 do hereby make and appoint
Agent") maintaining an address at--
D-dhi ? my true and lawful
attorney-in-fact for me and m my name, in my behalf.
My Agent shall have full power and authority to perform any act, power, duty, legal right
or obligation whatsoever that I now have or may later acquire in connection with or
relating to, any person, item, transaction, thing, business, property, real or personal,
tangible or intangible, or matter whatsoever as I could do if personally present. I hereby
ratify and confirm all acts that my Agent, or my Agent's substitute or substitutes, shall
lawfully do or cause to be done by virtue of this power of attorney and the rights hereby
granted. My Agent's powers and authority shall empower him (her) to do any or all of the
following, each of which is defined in 20 Pa.C.S.A.5603 (relating to implementation of
power of attorney):
I. "To make limited gifts."
2. "To create a trust for my benefit"
3. "To make additions to an existing trust for my benefit"
4. "To claim an elective share of the estate of my deceased spouse."
5. "To disclaim any interest in property."
6. "To renounce fiduciary positions."
7. "To withdraw and receive the income or corpus o£a trust"
8. "To authorize my admission to a medical, nursing, residential or similar
facility and to enter into agreements for my, care.,,
9. "To authorize medical and surgical procedures."
10. "To engage in real property transactions."
11. "To engage in tangible personal property transaction."
12. "To engage in stock, bond and other securities transactions."
13. "To engage in commodity and option transactions."
14. "To engage in banking and financial transactions."
15. "To borrow money."
16. "To enter safe deposit boxes."
17. "To engage in insurance transactions."
18. "To engage in retirement plan transactions."
19. "To handle interests in estates and trusts."
20 "To pursue claims and litigation."
21. "To receive government benefits."
22. "To pursue tax matters."
23. "To make an anatomical gift of all or part of my body."
-2-
This Durable Power of Attorney and the rights, powers, and authority of my Agent shall
become effective immediately upon execution of this instrument. The rights, powers, and
authority of this document shall be exercisable notwithstanding my subsequent disability
or incapacity. This Power of Attorney shall not terminate on my subsequent disability,
incapacity or lack of mental competence (except as provided by any applicable statute).
As used herein, "disability" or "incapacity" shall mean a lack of capacity to receive and
evaluate information effectively, to communicate decisions, and/or to manage my
financial resources and affairs properly. This Durable Power of Attorney shall be valid
notwithstanding the lapse of time since its execution.
My Agent shall be entitled to reimbursement of all reasonable expenses incurred as a
result of carrying out any provision of this Power of Attorney. If desired, my Agent shall
also be entitled to reasonable compensation for any services provided as my Agent
If so requested by myself or any authorized personal representative or fiduciary acting on
my behalf; my Agent shall provide an accounting for all funds handled and all acts
performed as my Agent.
This Power of Attorney shall be construed as broadly as a General Power of Attorney.
The listing of specific terms, rights, acts or powers are not intended to restrict or limit the
definition or scope of powers granted herein in any manner. If any part of this document
is held to be invalid, illegal or unenforceable under applicable law, then the remaining
unaffected parts ofthe document shall still remain in full €orce and effect and not be
affected by any partial invalidity.
No person needs to inquire as to the reasons for the use or issuance of this power-o£-
attorney or as to the disposition of any proceeds paid to my Agent based on this
document
The powers granted to my Agent by this power-of-attorney are limited to the extent
necessary to prevent (a) my income to be taxable to my Agent; (b) my Agent to have any
rights or ownership with respect to any life insurance policies I may own on the life of
my Agent; and/or (c) my assets to be subject to a general power of appointment by my
Agent.
Any third party who receives a copy of this document may act under it. Revocation of the
power of attorney is not effective as to a third party until the third party has actual
knowledge of the revocation. I agree to indemnify the third party for any claims that arise
against the third party because of reliance on this power of attorney. If this Durable
Power of Attorney is terminated by operation of law, any person relying in good faith on
the authority of this document, without notice of such termination, shall be held harmless.
Agent shall not be liable for losses resulting from judgment errors made in good faith.
However, Agent will be liable for breach of fiduciary duty, failure to act in good faith
and/or willful misconduct, while acting under the authority of this Power of Attorney.
-3-
I may revoke this Power of Attorney at any time by providing written notice to my
Agent.
Signed on (date), at (city),
Pennsylvania.
Signature ofPrincipa(
Witness Signature:
Name:
Cit;
State:
Witness Signature:
Name:
City
State:
State of PENNSYLVANIA )
County of &w I(,z r ss
instrument was ackno (edged bet re this IQ day of
2- ? by f f (name of
r is personally known to me or who has produced
?L#ka cPl(p(? as identification.
COMMONWEALTH OF PENNSYLVANIA
NOTARIAL SEAL
DEBORAH WARREN, Notary Pubic
Stuppwdutg Up., Cumberland Co"
My Commission Expires Nov. 8. 2005
Signature of person taking acknowledgment
(Notary Public)
Name typed, printed, or stamped
-4-
Acknowledgment by Agent
I. l P r I n LCAI -p Y- have read the attached power of attorney
and am the er identified as the Agent for the Principal. I hereby acknowledge that in
the absence of a specific provision to the contrary in the power of attorney or in 20
Pa.C. S. when I act as agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from my assets,
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf
of the principal.
Signature ofAgent
fit- w) -/-)q
Date
-5-
20 Pa.C.SA. Section 5606 states that an affidavit executed by the agent under a power of attorney stating
that he did not have at the time of exercise of the power actual knowledge of the termination of the power
by revocation, death or, if applicable, disability or incapacity or the filing of an action in divorce and that, if
applicable, the specified fmare time or contingency has occurred, is conclusive proof of the nauevoixt on
or nonteimination of the power at that time and conclusive proofthat the specified time or contingency has
occurred.
-6-
HEALTH CARE CENTER
121 Walnut Bottom Road (717) 530-8300
Shippensburg, Pennsylvania FAX (717) 530-8304
17257-9005 TTY 1-800-654-5984
ADMISSION AGREEMENT
This Agreement is between Shippensburg Health Care Center (the "Facility" or "we" and)
>p i„Iee T• G iWAy (the "Resident" or "you") and, if you or the court have
designated an individual to qa?ct on your behalf, or there is another individual to act on your
behalf, or operation of law, h 14 51?i W I - Won i a, ("your representative"). A
checklist of the rights and responsibilities applicable-76-your'
pplicable to your representative is listed in Exhibit I
and is incorporated into this Agreement.
Paving for Your Care
If you are applying to this facility as a private-pay resident, you must provide all financial
information requested by us. If we later find that the information 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 Pay for Your Care
Only you and your insurer can be required to pay for your care. No other person, (i.e. a family
member, friend, 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 terms 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 Pay 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, pharmacy 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"
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.
Holdinti 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 may or may not have a bed hold policy. We will discuss this if it
applies to you.
Your Right to Make Complaints and Suggest Chanties 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, PA 17257
717-530-8300
Ombudsman
Office of Aging
16 West High Street
Carlisle, PA 17013
717-240-6110
717-532-7286 Ext. 6110
Peter E. Perini, Sr.
President
Magnolia Management, Inc.
1710 Underpass Way
Hagerstown, MD 21740
301-745-8700
Department of Health
100 North Cameron Street
2nd Floor
Harrisburg, PA 17101
717-783-3790
Your Right 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 Discharge
You have the right to remain here, and you may not be transferred, relocated or discharged
against your will, except for the following reasons: (1) 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 Right 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.
?5.?_L Exhibit 1. Rights and Obligations of Representatives.
L2) Exhibit 2. For Private Pay Residents:
(a) Items and services covered by daily rate.
(b) Items and services not covered by daily rate.
1Cjjj Exhibit 3. How to Apply For and Use Medicare and Medicaid Benefits.
Exhibit 4. (a) Items and Services Covered by Medicaid.
(c) Items and Services Not Covered by Medicaid.
LCX?) Exhibit 5. Physicians Who Practice at the Facility.
LLD Exhibit 6. Legal Rights of Pennsylvania to Decide Future Medical Treatment.
Exhibit 7. Policies and Procedures Concerning Your Personal Funds and Your
Personal Property.
CLAD Exhibit 8. Services Provided by Outside Health Care Providers.
Chanties in Law
Any provision of this Contract that is found to be invalid or unenforceable as a result of a change
in State or Federal law will not invalidate the remaining provisions of this 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.
IN WITNESS WHEREOF, the parties have executed this Contract on this , day of
Witness /Xarrv D. Cot1Y 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 lights and responsibilities, the
Facility may require the signature of another person on this contract. The other person may be:
(1) Ana healthcare agent under an advance directive for medical care; (2) A guardian or
kLWer of Attome the person; (3) A surrogate or family member.
Responsible Party (Name)
?2-)
Title: Indica het per you are (1), (2) or (3)
EDITS
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. Items and Services Covered by Medicaid.
C. 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.
EI'BIT 1
RIGHTS AND OBLIGATIONS OF REPRESENTATIVE
The Representative shall have the right to be notified by the Facility of any event or, occurrence ..
involving the Resident; which directly affects any obligation, of the Representative under this
'Agreement -Representative agrees to, assume-independently, ,under- this, Agreement, the
following,,. obligations and: is entitled to the following. rights,!.as indicated- by-Representative's
initials accompanying any of the following provisions:
• Representative agrees to be responsible for ensuring, that. anyrpayment-from th-Wxesident to
which the Facility is, entitled, pursuant to this Agreement shall•.he,paid: to,the-Eaeility in. a
timely manner. 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 civilpenaltyfor willful violation 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 information 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 1, 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 funds are.exhausted •during the
Resident's-stay and, the Resident is -eligible to apply for benefits.under.the :Medicaid'Progran , .
the Representative shall assist the Resident and the Facility with : any application for
Medicaid benefits. Representative. further•_agrees to, act; ,on:behalf -,of°the',Resident,., to .
" facilitate any Medicare; Veterans Administratiomor 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.
EXIMTT 2.A
Private Pay Residents
A. Items and Services Included in the Daily Rate
The items and services included in the daily rate, and their related charges, are listed below:
Description of Items and Services Included in the Daily 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 Daily Room Rates (effective July 1, 2003)
Special Care
Program
Private Rooms $179.00 $189.00
Semi-Private Rooms $164.00 $184.00
Triple/QuadRooms $152.00 $174.00
Medicare co-pay: $105.00
EIT 2.B
ITEMS AND SERVICES NOT COVERED BY TIRE 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
IV 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 23, Continued)
ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE
(refer to the Ancillary Charge List for additional costs)
Item
Telephone
Television/Cable per month
Beauty/Barber Shop Services:
Permanent
Haircuts and Blow-dry
Hair Sets
Cut Only
Color
Personal Laundry
Personal Dry Cleaning
Physical Therapy Service
Occupational/Speech Therapy
IV Therapy
Aerosol Therapy
Charge
Direct bill from telephone company
$7.00 per month
$35.00
$10.25
$8.25
$8.25
$30.00
$45.00 per month
Same as billed by cleaner
Determined by level of care required
Determined by level of care required
Charge list will be provided by contract
pharmacy prior to delivery of services
Determined by level of care required
Shippensburg Health Care Center cordially invites family members, guests and friends to join
our Resident's at meat times.
The prices for guest trays, effective July 1, 2001 are as follows:
Breakfast A $4.00
Breakfast B $4.00
Lunch A $4.00
Lunch B $4.00
Dinner A $4.00
Dinner B $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.
EDIT 3
The following summarizes the Medicare and Medicaid programs. It also tells you who to call for
more detailed information. 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. The following 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
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 Exhibit 4 for information about covered and non-covered items.
Your Contribution - Medicare
Medicare does not pgy 100% of the cost of covered services., You will 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 Eligible - Medicare
People 65'years old or olderwho 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 Eligible -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.
C. A certain amount of money for burial arrangements.
How to Aaaly - 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 Apply - 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 you have a Ouestion or Problem - Medicare
If Medicare denies a claim, you have the right to appeal the denial. You may appeal by writing
to: Aetna Medicare Claim Administration
501 Office Center Building
Fort Washington, PA 19034
(215) 643-7200
Whom to Contact if you 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)
- Not applicable
whom to Contact if vow, have Incurred Medical Expenses prior to your -MA Effecflve:Date
- Medicaid
Medical bills that you received in the 3 months prior to'receiving.:Medicaid+may be covered by
Medicaid. Contact:
County Board of Assistance Office
33 Westminister Drive
P.O. Box 599
Carlisle, PA 17013
(717) 249-2929
(800) 269-0173
E}IEE3IT 4.A
A. Items and Services Covered by the Medicaid Per Diem Rate
?. Regular room; -dietary 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•l Fnited to ^ administration of oxygen
..'and related: medications; hand feeding, incontinency,. care x,trayiservice. and
enemas.
• ...Basic Beauty/]Barber Services. The facility must provide' shampooing and hair
care which is considered necessary for hygiene. The facility must inform the
resident of the types and frequency of the services provided.
• Items funished routinely and relatively uniformly ?to._aWresidents, such as water
pitchers, basins, and bedpans.
• Items furnished, distributed, or used individually in:.=all 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-emergencymedical 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.
EXMIT 4.B
B. Items and Services Not Covered b 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. they 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 request 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 brand whiehy is: t 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.
EX BTT 5
PHYSICIANS WHO PRACTICE AT THE FACII PTI'
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; PA 17201
(717) 264-6511
Dr.: Paul Orange, M.D. 4225 Lincoln Way East
Fayetteville, PA 17222
(717) 352-3616
Dr: Baxter Drew Wellmon, II, D.O.; P.C. 12 Walnusbu Bottom
PA 1R S d
PP g
(717) 532-3211
Dr. Hong S. Park, M.D. 120 North Seventh Street
Chambersburg, PA 17201
(717) 267-7735
EXHIBTT 6
LEGAL RIGHTS OF PENNSYLVANIANS TO DECIDE ABOUT HEALTH CARE
You Have the Right to Decide About Your Health Care
Adults. generally-. have the- right- to. decide if, they want medical. treatment;:unless- they are. not.... competent °Thisright includes decisions about treatments that. extend life;afe-support machines,•
or feeding tubes.
Sometimes; an accident or, illness.takesaway- a person'sabiJ ty.to make•healthaeare.choic6&, But -,
- the-decisionrstill must be made; . If you are unable -to make then ;=others will Their wilk.decide
based on your wishes, or your best interests if your wishes are unknown.
Pennsylvania law gives you the right to make many healthcare 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.
Naming a Health Care Agent
You; 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 be your agent. Your agent can be
a family member or a friend.
You choose !when, your agent: can decide for you - right away; if,you-want; or, only after two
doctors agree .thatyou are notableto decide for. yourself. Youralso:choosethelands of decisions
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 friends or family disagree.
Using 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.
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
-x. relative: would be asked-to, make health. care- decisions for.. you..:Your.spouse;. adult. children;,,,:
parents; or• adult brothers. and sisters; in that order, are considered your. closest relatives. r If these
:relatives.-are not available, another relative or close friend: can; make, decisions for you.. A
Surrogate, .thouAh might :have.less- authority to- decide .:agamst.life-sustammgprocedtues:than a,. healthcare agent.
If:there is no one. to be. a:surrogate, a court. might have. to, appoint I w guardian twmake your
medical decisions: The guardian-might-be somebody who does=not know-.youipersonafly:,;4•, .
How Do You 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 about .the°,medical:issues involved in
_.,t :your. care..; T61L°those•caring for you about your decisions and; give them.•a;copyzof aml.:advance
directive.
For a free copy of a Living Will or Advance Directive form contact:
State Representative Jeff. Coy
39 West King Street
Shippensburg; PA 17257
(717) 532-1707
or
Cumberland County Office of Aging
Human Service Building
16 West High Street
Carlisle, PA 17013
(717) 532-7286 Ext. 6110
(717) 240-6110
EXHMrr 7
POLICIES AND PROCEDURES CONCERNING YOUR PERSONAL FUNDS
AND YOUR PERSONAL PROPERTY
A. Your Rights:
I .You have. the right to. keep and use your. personaLproperty,::including some
furnishings and clothing, so' long as there is enough ?.space:andother residents are
not. inconvenienced. You also have the' right" to security. for. your, personal
possessions.
2. You have>the,right°to-manage your financiaLaffairsunless=x:eouR•detem ines.that
you are?•. incapacitated:., or, the Social Secsurt?u yaAdrnuristratom:rseleets 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 personal: funds, you, may -withdraw -your
money: that .we keep in the Facility. during.. the+Facility's:,business?.hours:.., 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 ! perform your banking. transaetionsyc 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) 240-6110
(Exhibit 7, Continued)
b. Cumberland County Board of Assistance
33 Westminster Drive
P.O. Box 599
Carlisle, PA 17013
(717) 249-2929
(800) 269-0173
c. The Department of Health -
Division of Nursing Care Facilities
100 North Cameron Street
2°d Floor
Harrisburg, PA 17101
(717) 783-3790
B. Our Responsibilities:
1:. ., .We will, provide -a reasonable amount of, secure: spacea•-£or,?yau to--,.keep,: your
`clothing and other personal property.: We must investigate any damage fo:+or loss
of your personal property.
..2.,• . Jf you want us to: manage $50.004or,.less:ofyour,personal-fluids;=we.will deposit
r this money in-a non-interest bearing account or•a petty cash ;fimd.
3:.; If:you, want us Ao• manage morel than. $50.0.0cof. your personal-Ifunds;. we will:
.
deposit this money.in an interest bearing account that% is! 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 accounting 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 your account balance
becomes too high: If you are to remain eligible for 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 personal funds to pay for an item or service that Medicare
or Medicaid covers.
7. We will maintain adequate fire and theft coverage to protect your funds and
personal property that are kept at the Facility. We shall also obtain a surety bond
or otherwise assure the security of 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 our. possession. .If we
have deposited. your. personal funds in a bank account,. we: will, ensure, that
this money is made available to your of your. authorized representative
within 30 days.
b: If we are. your representative payee:!for:Social=SecudWL-benefits,,,we.will
promptly ask the Social Security Administration : to:: name a : new
representative payee and we will transfer-your•moneyto- that persona -
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.estatewithin.30 days. We
will: immediately notify. any governrnentsagencythat- paidcfor. ail, or:part of
your care. in our Facility. That agency: shallhave the right to assist us in
determining what to do with your property.
b. If a government agency did not pay for your care;.we.will.immediately
notify.:your.representative or next of kin to+determine.what toAo with.your
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.
EXIUBIT 8
SERVICES PROVIDED BY OUTSIDE HEALTH CARE PROVIDERS
Some. of the. services available.in. the Facility; such, as pharmacy., services, are. provided by.outside
health care providers:? 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:
Whether we have
Provider's Name, a ,financial
Address and =Interest in
Type of Service Telephone Number the Provider
Physician Dr. Yogindra Balhara
761 Fifth Avenue No
Chambersburg, PA 17201
(717) 264-6185
X-Ray Services Mobil X-Ray Services
The Chambersburg Hospital No
112 N. Seventh Street
Chambersburg, PA 17201
(717) 267-6356
Lab Services The Chambersburg Hospital
112 N. Seventh Street No
Chambersburg, PA 17201
(717) 267-7153
Pharmaceutical Pharmacare
Route 3, Box 3-A No
Cumberland, MD 21502
(301) 777-1773
Podiatrist Dr. Peter Holdaway
1936 Scotland Avenue No
Chambersburg, PA 17201
(717) 264-5211
Podiatrist Dr. Kirk Davis, D.P.M.
601 Wayne Avenue No
Chambersburg, PA 17201
(717) 267-2255
(Exhibit 8, Continued)
Type of Service
Provider's Name,
Address and
TelMhone Number
Whether we have
a financial
Interestin
the Provider
Dentist Health Drive No
928 Jaymor Road
Suite C-190
Southampton, PA 18966
(215) 942-9950 FAX (215) 942-9954
Hospital
Inpatient or
Carlisle Hospital
No
Emergency Chambersburg Hospital No
Room Fulton Co. Medical Center No
Hershey Medical Center No
Waynesboro Hospital No
... rve.. r ..... . r.vran t I-WO-289.0173 717.2104700
DEPARTMENT OF PUBLIC WELFARE
• • I , I • CUMBERLAND COUNTY ASSISTANCE OFFICE
I I • • • • 33 WESTMINSTER DRIVE
R O. BOX 589
BENEFIT EUG19LE ELIG 9? PENDING CARLISLE, PA 17013-NN
? ASSISTANCE After Me first rludr which may be a special amount you will receive S
CHECK ? Twice a Month ? Once a Month ? In the Mail ? At the Bank
MEDICAL ? You have a patient pay liability of $
ASSISTANCE g for Me notl
pe bagiviing and entlirg ? Eftecave Data
v
?.FOOD You will receive It for thl month(s) of Men you will receive food stamps in Me amount of $
STAMPS a month from to ? In the Mail ? At the Bank
NURSING HOME CARE )( Level of care authatzetl you are eapectetl to pay It a month bw•rtl
SOCIAL OTHER Your cars.
? SERVICES ? '
THE FOLLOWING PERSONS 'AREINCLUDED
.;i x i _r > :,1? > - _.iti ^wa
LINE ASSTx . FOODoc MEsccr D. SOC. LINE
NO NAME euF p T,
. r areu eeo,nre un NAME ,? „•....._ ._-
CODE
You are eligible for Nursing Home Care Medical Assistance effective 1!21G O
Report all changes within 10 days to your ongoing caseworker who is MIrs F
SEE ATTACHED.
Name
Name
TOTAL GROSS MONTHLY INCOME $
GROSS MONTHLY DEPENDENT CARE COSTS $
GROSS MEDICAL COSTS $
Telephone ter/Sewage
Electric kGarbagerrrash
Gas ty Installation
Oil er
GROSS UTILITY COSTSIUTILITY STANDARD' $
RENT/MORTGAGE $
TAXES $
INSURANCE COST ON HOME
TOTAL SHELTER COST $
$
CO RECORD NUMBER CAT CTR DIG DIST
I
21 je 3 27 PTiJ S
Name
TOTAL GROSS MONTHLY INCOME
GROSS MONTHLY DEPENDENT CARE
Name
Name
t$$$
Is _V7
TOTAL GROSS MONTHLY INCOME $
NET MONTHLY INCOMENET SEMI-ANNUAL INCOME $
INCOME LIMIT Is
Ls, QAL, z t'10 - 27oy
Workers Signature Data Telephone Number
r ?
DoRiiI cotowHy
2 / c d94)lU7 Q07TbM
SNIPPF-PSIQUkr) RN 1725
L J
you do not understand dur decision oihIai4 any questions, contact your worker.
^I ICLI'1' ^f%DV
'-` , • :, `. -LEGALHELP IS AVAILASLEAT
oR1?INHL TD PO A
LEGAL SERVICES, INC.
8 IRVINE ROW
CARLISLE, PA 17013-3019
717-243-9400 717-766-8475
CC TO /JAJ/Z.C/A)G NoME
CC- T'o DFFtCL` a.F AGIAJ5
EXHIBIT "C"
NAME --NrlnnA NnLzA.1-4
RECORD NUMBER q O ?p1?
INITIAL h
MO/YR'I MO/YR MO/YR
GROSS SSA 59 •4:0 -30•Db
DD
TOTAL GROSS UNEARNED J 9I• yD D . Db ?D 9 ,D p
ESTIMATED INTEREST
TOTAL INCOME USED
- PERSONAL CARE 0
ALLOWANCE D 1-4 0
- COMMUNITY SPOUSE/
HOME MAINTENANCE
GROSS PATIENT PAY (53) 1 . D_ l ?D 7 . co
- MEDICAL EXPENSES LESS MEDICAL EXPENSES PAID MONTHLY
(See below)
NET PATIENT PAY (57)
MEDICAL EXPENSES LISTED
t[Q'jE: Future changes in medical expenses
should be reported to the Nursing Facility.
MO/YR MO/YR
DRUGS (54)
MEDICARE (55)
BC/BS/OTHER MEDICAL INS (55)
OTHER MEDICAL (56)
MONTHLY TOTAL
SIGNATURE DATE
REMINDER: The resource limit is $2,000/$2400. See attached Addendum
with $6000 disregard
STATEMENT
SHIPPENSBURG HEALTH CARE CTR
121 WALNUT BOTTOM RD
SHIPPENSBURG, PA 17257
Resident: DORINDA CONWAY
Facility Phone: 717-530-8300
Statement Date: 05119/05
Kierstyn Walker
312 HARVEST LANE
Shippensburg, PA 17257
Date Service Through Qty Description
Amount
Sub Total as of 04/30/05
Charges
05/06/05 05/01/05 05/06/05 6 Patient Liability
Sub Total 769.00
Balance 3,504.55
'ash Recei pts/Adjustments
05/01/05 02/01/05 02/04/05 4 ADJ. Patient Liability -576.40
Sub Total -576.40
Balance 2,928.15
Ancillary/Other Charges
05/01/05 04/18/05 04/18/05 1 Barber & Beauty 8.25
05/19/05 05/19105 05/19/05 1 CABLE 7.00
Sub Total 15.25
Balance as of: 05119105 2,943.40
Projected Prebill Charges
06/01/05 06/01/05 06/06/05 6 Prebill Patient Liability
Sub Total
Total Amount Due
2,735.55
769.00
P A S T D U E
PLEASE REMIT
EXHIBIT ^D11
769.OC
769.00
3,712.40
Paqe
\J
cw --i
7 G.n
W
SHIPPENSBURG/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
DORINDA T. CONWAY,
KIERSTYN L. WALKER,
individually and as
attorney-in-fact for
Dorinda T. Conway,
Defendants
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 2982 CIVIL TERM
PRAECIPE TO ENTER DEFAULT JUDGMENT
PURSUANT TO Pa.R.C.P. 1037
TO THE PROTHONOTARY:
Please enter judgment in favor of the Plaintiff, Shippensburg/South Hampton Manor, L.P.
and against the Defendants, Dorinda T. Conway and Kierstyn L. Walker, for failure to file an
answer to the Complaint of Plaintiff.
A true and correct copies of the Notices of Default are appended hereto as Exhibit "A."
A true and correct copies of the Certificates of Mailing for the Notices of Default are
appended hereto as Exhibit "B." I certify that the Notice of Default was given in accordance
with Pa.R.C.P. 237.1.
Plaintiff requests judgment in the amount of $3,712.40 as set forth in the Complaint.
Respectfully submitted,
O'BRIEN, RIC & S R
1 "
David A. Baric, Esquire
I.D. # 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
SHIPPENSBURG/
SOUTH HAMPTON MANOR, L.P.
Plaintiff
V.
DORINDA T. CONWAY,
KIERSTYN L. WALKER,
individually and as
attorney-in-fact for
Dorinda T. Conway,
Defendants
TO: Dorinda T. Conway
121 Walnut Bottom Road
Shippensburg, Pennsylvania 17257
Date of Notice: July 20, 2005
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2005- 2982 CIVIL TERM
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN
APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE
COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST
YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A
JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU
MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE
THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR
CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND
OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
Telephone: (717) 249-3166
nOEN, BARK ND SCH R
i
David A. Baric, Esquire
19 West South Street
Carlisle, PA 17013
(717) 249-6873
EXHIBIT "A"
SHIPPENSBURG/ IN THE COURT OF COMMON PLEAS OF
SOUTH HAMPTON MANOR, L.P.: CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
V. NO. 2005- 2982 CIVIL TERM
DORINDA T. CONWAY,
KIERSTYN L. WALKER,
individually and as
attorney-in-fact for
Dorinda T. Conway,
Defendants
TO: Kierstyn L. Walker
312 Harvest Lane
Shippensburg, Pennsylvania 17257
Date of Notice: July 20, 2005
IMPORTANT NOTICE
YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED TO ENTER A WRITTEN
APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE IN WRITING WITH THE
COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS SET FORTH AGAINST
YOU. UNLESS YOU ACT WITHIN TEN DAYS FROM THE DATE OF THIS NOTICE, A
JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HEARING AND YOU
MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHTS. YOU SHOULD TAKE
THIS NOTICE TO A LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR
CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLOWING OFFICE TO FIND
OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
Telephone: (717) 249-3166
nz:C ?D
Lf
David A. Baric, Esquire
19 West South Street
Carlisle, PA 17013
(717) 249-6873
"I
PS Form 3817, January 2001
MAIL, DOES NOT
U.S. POSTAL SERVICE CERTIFIC
WY aE USEO FOR DOMESTIC AND INTERNATIONP
ROVIDE FOR IN SURANCE-POSTMASTER
Received From l : QQ ??CIf.YI, L7QYIfi°l' SCSI
'(,pr?isl4i, PKt 11413
I niece of ordinary mad addressed to
f-rs-Nn Uo Walftr
312, `j NnrMqgA- 1 nnf
PS Form 3817, January 2001
MAIL, DOES NOT
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EXHIBIT "B"
19 Wt;sF S0 0h 6-lne
Carlisle , PA 1"1 bl3
CERTIFICATE OF SERVICE
I hereby certify that on August 9, 2005, I, David A. Baric, Esquire, of O'Brien, Baric &
Scherer did serve a copy of the Praecipe To Enter Default Judgment Pursuant To Pa.R.C.P. 1037,
by first class U.S. mail, postage prepaid, to the parties listed below, as follows:
Dorinda T. Conway
121 Walnut Bottom Road
Shippensburg, Pennsylvania 17257
Kierstyn L. Walker
312 Harvest Lane
Shippensburg, Pennsylvania 17257
David A. Baric, Esquire
C
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IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
PRAECIPE FOR WRIT OF EXECUTION
Caption: ( ) Confessed Judgment
SHIPPENSBURG/ (' ) Other
SOUTHAMPTON MANOR, L.P.,
File No. 2005-2982 Civil Term
Plaintiff
vs. Amount Due $3,712.40
DORINDA T. CONWAY, Interest
KIERSTYN L. WALKER,
individually and as Atty's Comm
attorney-in-fact for Costs
Dorinda T. Conway, Defendant
TO THE PROTHONOTARY OF THE SAID COURT:
The undersigned hereby certifies that the below does not arise out of a retail installment sale, contract, or
account based on a confession of judgment, but if it does, it is based on the appropriate original proceeding filed
pursuant to Act 7 of 1966 as amended; and for real property pursuant to Act 6 of 1974 as amended.
Issue writ of execution in the above matter to the Sheriff of Cumberland County,
for debt, interest and costs, upon the following described property of the defendant(s)
personalty of Kierstyn L. Walker
312 A;wve-.?T LANi;
5Mj'&& Nseu?? , ? 170SY
PRAECIPE FOR ATTACHMENT EXECUTION
Issue writ of attachment to the Sheriff of County, for debt, interest and
costs, as above, directing attachment against the above-named garnishee(s) for the following property (if real
estate, supply six copies of the description; supply four copies of lengthy personalty list)
and all other property of the defendant(s) in the possession, custody or control of the said garnishee(s).
(Indicate) Index this writ against the garnishee(s) as a lis penderyS against real tale oft
defendant(s) described in the attached exhibit.
September 8, 2005/'2/
Date Signature:
Print Name: David A. Baric, Esquire
Address: 19 West South Street
Carlisle, PA 17013
Attorney for: Plaintiff
Telephone: (717) 249-6873
Supreme Court ID No.: 44853
(over)
Notes: If real property, supply six copies of description including improvements and an original and copy of
affidavit of ownership (PaR.C.P. No. 3129).
If lengthy personalty list, supply four copies of list.
To index writ, file separate praecipe with writ.
o a ? ?
A? ti c:
WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF CUMBERLAND)
N005-2982 Civil
CIVIL ACTION - LAW
TO THE SHERIFF OF CUMBERLAND COUNTY:
To satisfy the debt, interest and costs due Shippensburg/Southampto Manor, L.P. Plaintiff (s)
From Dorinda T. Conway, Merstyn L. Walker, Individually and as attorney-in-fact for Dorinda T.
Conway
(1) You are directed to levy upon the property of the defendant (s)and to sell Personalty of Kiersty L.
Walker at 312 Harvest Lane, Shippensburg, PA 17257
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of
GARNISHEE(S) as follows:
and to notify the gamishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant
(s) or otherwise disposing thereof;
(3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount Due$3,712.40
Interest
Atty's Comm %
Atty Paid $36,75
Plaintiff Paid
Date: September 8, 2005
(Seal)
L.L.$.50
Due Prothy $1.00
Other Costs
Prothono
By:
Deputy
REQUESTING PARTY:
Name David A. Baric, Esq.
Address: 19 West South Street
Carlisle PA 17013
Attorney for: Plaintiff
Telephone: 717-249-6873
Supreme Court ID No. 44853
r c%+?
caw st ?'?' FROM
,.,a q f?rr t';tr ra r*;
t
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w1 ii ?.5l",
R. Thomas Kline, Sheriff, who being duly sworn according to law, states this
Writ is returned ABANDONED, no action taken in six months.
Sheriff's Costs: Advance Costs: 150.00
Sheriff's Costs 87.97
Docketing 18.00 62.03
Poundage 1.73
Advertising
Law Library .50
Prothonotary 1.00 Refunded to Atty on 5/16/06
Mileage c,- 16.00
M{sc: `
Sukharge- 30.00
Levy n 20.00
Post Ponecfiale
Certified Mail
Postage .74
Garnisheq,
TOTAL ti 87.97
Jo 4/6 Sworn and Subscribed to before me
lef
So Answers;
this day of R. Thomas Kline, Sheriff
't
20 D. t _
By CLu.- i,.,?Z(U
Prothon 'c
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S ? .Z d b - ?3S SOOt
a?.
l??0 ck S- (4
e 1,7
??
WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF CUMBERLAND)
N005-2982 Civil
CIVIL ACTION - LAW
TO THE SHERIFF OF CUMBERLAND COUNTY:
To satisfy the debt, interest and costs due Shippensburg/Southampto Manor, L.P. Plaintiff (s)
From Dorinda T. Conway, Kierstyn L. Walker, Individually and as attorney-in-fact for Dorinda T.
Conway
(1) You are directed to levy upon the property of the defendant (s)and to sell Personalty of Kiersty L.
Walker at 312 Harvest Lane, Shippensburg, PA 17257
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of
GARNISHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant
(s) or otherwise disposing thereof;
(3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount Due$3,712.40
Interest
Atty's Comm %
Atty Paid $36,75
Plaintiff Paid
Date: September 8, 2005
(Seal)
L.L.$.50
Due Prothy $1.00
Other Costs
rothon
By:
Deputy
REQUESTING PARTY:
Name David A. Baric, Esq.
Address: 19 West South Street
Carlisle PA 17013
Attorney for: Plaintiff
Telephone: 717-249-6873
Supreme Court ID No. 44853
r • .A
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA
CIVIL DIVISION
PRAECIPE FOR WRIT OF EXECUTION
. ? Other
. File No.
V . : Amount Due $3,712.40
Caption:
SHIPPENSBURG/
SOUTHAMPTON MANOR, L.P.,
Plaintiff
[] Confessed Judgment
2005 - 2982 Civil Term
DORINDA T. CONWAY, Interest 325.22 ,l
KIERSTYN L. WALKER, , ?.?
individually and as Atty s Comm 500.00 9 4.
'T "
attorney-in-fact for Costs 1-6rr.-90 O
Dorinda T. Conway Defendant
TO THE PROTHONOTARY O? THE SAID COURT:
The undersigned hereby certifies that the below does not arise out of a retail installment sale,
contract, or account based on a confession of judgment, but if it does, it is based on the appropriate original
proceeding filed pursuant to act 7 of 1966 as amended; and for real property pursuant to Act 6 of 1974 as
amended.
Issue writ of execution in the above matter to the Sheriff of Cumberland
County, for debt, interest and costs, upon the following described property of the defendant (s)
personalty of Kierstyn L Walker, 312 Harvest Lane.
Shippensburct, Pennsylvania,-17257.
PRAECIPE FOR ATTACHMENT EXECUTION
Issue writ of attachment to the Sheriff of Cumberland County, for debt, interest
and costs, as above, directing attachment against the above-named garnishee(s) for the following property
(if real estate, supply six copies of the description; supply four copies of lengthy personalty list)
and all other property of the defendant(s) in the possession, custody or control of the said garnishee(s).
(Indicate) Index this writ against the garnishee (s) as a lis pen against real o
defendant(s) described in the attached exhibit.
Date January 26 , 2007 Signature:
Print Name
Address:
Attorney for:
David A. Baric, Esquire
19 West South Street
Carlisle, PA, 17013
Plaintiff
Telephone: (717) 249-6873
Supreme Court ID No: 4 4 8 5 3
a
S
14
C
y
WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF CUMBERLAND)
N005-2982 Civil
CIVIL ACTION - LAW
TO THE SHERIFF OF CUMBERLAND COUNTY:
To satisfy the debt, interest and costs due Shippensburg/Southampton Manor, L. P. Plaintiff (s)
From Dorinda T. Conway, Kierstyn L. Walker, individually and as attorney-in-fact for Dorinda T.
Conway
(1) You are directed to levy upon the property of the defendant (s)and to sell Personalty of Kierstyn L.
Walker, 312 Harvest Lane, Shippensburg, Pennsylvania 17257.
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of
GARNISHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the defendant
(s) or otherwise disposing thereof;
(3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount Due $ 3,712.40
Interest $325.22
Atty's Comm %$500.00
Atty Paid $253.11
Plaintiff Paid
Date: January 26, 2007
(Seal)
L.L.
Due Prothy $1.00
Other Costs
- ?IaQ 44
C tis R. Lon r thonotary
By:
Deputy
REQUESTING PARTY:
Name David A. Baric, Esquire
Address: 19 WEst South Street
Carlisle, Pa. 17013
Attorney for: Plaintiff
Telephone: (717) 249-6873
Supreme Court ID No. 44853
R. Thomas Kline, Sheriff, who being duly sworn according to law, states this
Writ is returned ABANDONED, no action taken in six months.
Sheriff's Costs:
Docketing
Poundage
Advertising
Law Library
Prothonotary
Mileage
Misc.
Surcharge
Levy
Post Pone Sale
Certified Mail
Postage
Garnishee
TOTAL
18.00
1.77
1.00
17.60
30.00
20.00
1.56 n
89.93 ? ` q???T'?
t ?
Advance Costs: 150.00
Sheriff's Costs 89.93
60.07
Refunded to Atty on 09/11/07
So Answers,
R. Thomas Kline, Sheriff
By ?C Y J
q€ _? d o€ Ntlc ?aot
? 31?34iS ?H
Wi?
"q
0
C
U
WRIT OF EXECUTION and/or ATTACHMENT
COMMONWEALTH OF PENNSYLVANIA)
COUNTY OF CUMBERLAND)
N005-2982 Civil
CIVIL ACTION - LAW
TO THE SHERIFF OF CUMBERLAND COUNTY:
To satisfy the debt, interest and costs due Shippensburg/Southampton Manor, L. P. Plaintiff (s)
From Dorinda T. Conway, Kierstyn L. Walker, individually and as attorney-in-fact for Dorinda T.
Conway
(1) You are directed to levy upon the property of the defendant (s)and to sell Personalty of Kierstyn L.
Walker, 312 Harvest Lane, Shippensburg, Pennsylvania 17257.
(2) You are also directed to attach the property of the defendant(s) not levied upon in the possession
of
GARNISHEE(S) as follows:
and to notify the garnishee(s) that: (a) an attachment has been issued; (b) the garnishee(s) is enjoined from
paying any debt to or for the account of the defendant (s) and from delivering any property of the-defendant
(s) or otherwise disposing thereof;
(3) If property of the defendant(s) not levied upon an subject to attachment is found in the possession
of anyone other than a named garnishee, you are directed to notify him/her that he/she has been added as a
garnishee and is enjoined as above stated.
Amount Due S 3,712.40
Interest $325.22
Atty's Comm %$500.00
Atty Paid $253.11
Plaintiff Paid
Date: January 26, 2007
(Seal)
L.L.
Due Prothy $1.00
Other Costs
2Aza Ao:?-2kl - -
RCurtig'R. Long,
By:
Deputy
REQUESTING PARTY:
Nan"avid A. Baric, Esquire
Address: 19 WEst South Street
Carlisle, Pa. 17013
Attorney for: Plaintiff
Telephone: (717) 249-6873
Supreme Court ID No. 44853