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HomeMy WebLinkAbout05-3527 Andrew J. Benchofl~ Esquire Komfietd & Benchofl: LLP Attorney tor Plaintiff 17 North Church Street Waynesboro, PA 17268 (717)762-8222 FAX 762-6544 andrew(a)komfietd.net Atty. 1.0. 89159 PINEY PARTNERS, LP., t/dIb/a LAUREL CARE NURSING AND REHABILITATION CENTER, Plaintiff IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT, PA v. CUMBERLAND COUNTY BRANCH AGATHA HAUT and HENRY HENSON, SR, CIVIL ACTION - LAW Defendants NO. 2005- .) S ~ 7 C/{);l/82...~ 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 claims or relief requested by the Plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. PA Bar Association Lawyer Referral Service P.O. Box 186, 100 South Street Harrisburg, PA 17108 Telephone Number: 800-692-7375 PURSUANT TO THE FAIR DEBT COLLECTION PRACTICES ACT YOU ARE ADVISED THAT THIS LAW FIRM IS DEEMED TO BE A DEBT COLLECTOR ATTEMPTING TO COLLECT A DEBT. ANY INFORMATION OBTAINED WILL BE USED FOR THAT PURPOSE. AMERICANS WITH DISABILITIES ACT OF 1990 The Court of Common Pleas of Cumberland County is required by law to comply with the Americans with Disabilities Act of 1990. For information about accessible facilities and reasonable accommodations available to disabled individuals having business before the Court, please contact our office. All arrangements must be made at least 72 hours prior to any hearing or business before the Court. You must attend the scheduled conference or hearing. Andrew 1. Benchoft; Esquire Komfield & Benchoft: LLP Attorney for Plaintiff 17 North Church Street Waynesboro, PA 1726R (717)762-R222 FAX 762-6544 andrew(a)komfieldnet Atty. I.D. 89159 PINEY PARTNERS, L.P, t/d/b/a LAUREL CARE NURSING AND REHABILITATION CENTER, Plaintiff IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT, PA v. CUMBERLAND COUNTY BRANCH AGATHA HAUT and HENRY HENSON SR, CIVIL ACTION - LAW Defendants NO. 2005- :35' J.,.1 PLAINTIFF'S COMPLAINT AGAINST AGATHA HAUT AND HENRY HENSON, SR. NOW COMES, Plaintiff, Piney Partners, L.P., t/d/b/a Laurel Care Nursing and Rehabilitation Center, by and through its attorney, Andrew 1. Benchoff, Esquire, Kornfield & Benchoff, LLP, and sets forth Plaintiff's Complaint Against Agatha Haut and Henry Henson, Sf.: 1. Plaintiff is Piney Partners, L.P., a Pennsylvania Limited Partnership, trading and doing business as the Laurel Care Nursing and Rehabilitation Center ("LCNRC") with offices located at 6375 Chambersburg Road, Fayetteville, Adams County, Pennsylvania. 2. Defendant is Agatha Haut, an adult individual, with an address of 1128 Mainsville Road, Shipp ens burg, Franklin County, Pennsylvania 3. Defendant is Henry Henson, Sf., an adult individual, with an address of 1128 Mainsville Road, Shippensburg, Franklin County, Pennsylvania. 4. Defendant Agatha Haut is the mother of Defendant Henry Henson, Sr. COUNT I-BREACH OF CONTRACT Piney Partners, L.P., a Pennsylvania Limited Partnership, trading and doing business as Laurel Care Nursing and Rehabilitation Center v. Agatha Haut and Henry Henson, Sr. 5. Based on a Facility Admission Agreement, a copy of which is attached as Exhibit A, between the parties dated March 22, 2003, Plaintiff supplied nursing and medical care to Defendant Agatha Haut, on open account. 5. Defendant Henry Henson, Sf. signed said Facility Admission Agreement as the agent/legal representative/responsible party for Defendant Agatha Haut. 6. An invoice dated April 1,2005, which reflects the sums due Plaintiff for providing nursing and medical care to Defendant Agatha Haut, is attached hereto as Exhibit B and made a part hereof 7. There is due and owing Plaintiff from Defendants the debt of$71,499.45 8. In spite of repeated demands, Defendants have failed and continue to fail to pay upon the said open account. WHEREFORE, Plaintiff demands judgment against Defendants in the amount of $71,499.45 together with court costs, expenses, interest, reasonable attorney fees and such other damages as may be available at law. COUNT II-FRAUDULENT TRANSFER PURSUANT TO 12 PA.C.S.A. SECTION 5104 Piney Partners, L.P., a Pennsylvania Limited Partnership, trading and doing business as Laurel Care Nursing and Rehabilitation Center v. Agatha Haut and Henry Henson, Sr. 9. Paragraphs one through eight are incorporated and restated herein by reference. 10. On February 14, 2003, Defendant Agatha Haut purportedly transferred property lying and being situate in the Borough of Carlisle, Cumberland County, Pennsylvania, to Defendant Henry Henson, Sf. said property being more particularly described in Cumberland County Deed Book 255, Page 3982, which is attached hereto as Exhibit C and incorporated herein by reference. 11. Said transfer was for no or nominal consideration, to wit: $1.00. 12. Said consideration was not reasonably equivalent to the value of the asset transferred, which has an assessed value of$75,110.00. Please see Cumberland County Assessment Office Tax Card attached hereto as Exhibit D and incorporated herein by reference. 13. Said transfer was to an insider in that Defendant Henry Henson, Sr. is Defendant Agatha Haut's son. 14. It is believed and therefore averred that the transfer was of all or substantially all of Defendant Agatha Haut's assets 15. It is believed and therefore averred that Agatha Haut was insolvent or became insolvent shortly after the transfer was made. 16. Said transfer occurred shortly before the above debt was incurred. 17. It is believed and therefore averred that the transfer was made A. with the intent to hinder, delay or defraud any creditor of Defendant Agatha Haut; or B. without receiving a reasonably equivalent value in exchange for the transfer and Agatha Haul: (i) was about to be engaged in a transaction for which her remaining assets were unreasonably small in relation to the transaction; or (ii) intended to incur, or believed or reasonably should have believed that she would incur, debts beyond the debtor's ability to pay as they became due. WHEREFORE, Plaintiff demands that the transfer be declared void ab initio and that the Court direct Defendant Agatha Haut and/or an officer of the court to file of record such documents as are necessary to correct and void the fraudulent transfer and demands judgment against Defendants in the amount of $71 ,499.45 together with court costs, expenses, interest, reasonable attorney fees and such other damages as may be available at law . Respectfully submitted, KO~1D AND BENCHO BL VV'~'/~UU5 FRI 14:07 FAX I4J008/009 I verity that the statements made in this Complaint are true and COrrect, r understand that false statements herein are made subject to the penalties of 18 Pa. C.S.A. Section 4904, relating to unsworn falsification to authorities, PINEY PARTNERS, L.P., tJdlbla LAUREL CARE NURSING AND REHABILIT A nON CENTER 5 Ur~~ David Bolton, Administrator 3/21 /:J'D3FaciJity Admission Agreement Laurel and Rehabilitation Center I. PARTIES This Admission Agreement ("Agreement") is made this 220d day of March 2003 by and between Laurel Care Nursing and Rehabilitation Center, facility located at 6375 Chambersburg Road, Fayetteville, PA (the "Facility") AND Agatha Haut (the "Resident"), and/or Henry Henson, son/POA (Name of Agent or Legal Representative). ("Resident Representative"), on behalf of Resident, in consideration of the mutuai Covenants contained in the Agreement. The Parties designated above do hereby agree to the fOllowing terms, conditions, and arrangements regarding the provision of nursing and/or personai care to the Resident. II. TERM The term of this agreement shall commence on the 23'" day of March 2003 and continue in fuil-force and effect for one year, and shall renew annually thereafter, unless otherwise terminated as set forth herein. /lI.OBl/GAT/ONS OF FAC/l/TY Facility agrees to provide those basic items and services that Facility is licensed to prOVide and, if Faciiity is a nursing facility, those items and services determined necessary by Resident's physician and health care team. A. Facility represents and warrants that it has all the necessary qualifications and/or iicenses required by federal, state, and local iaws and regulations to provide long term care in this state. C. NONDISCRIMINATION STATEMENT_ The Faciiity welcomes all persons in need of its services and does not discriminate on the basis of age, disability, race, Color, national origin, ancestry, religion, political beliefs or sex. The Facility does not discriminate among persons based on their Sources of payment. IV. PAYMENT INFORMATION A. CHARGES_ The Resident agrees to pay Facility a Daiiy Rate to cover routine services, unless the Resident receives Medicaid, Medicare, or other Third Party coverage. The Daiiy Rate that the Resident agrees to pay, and the services Covered by the Daiiy Rate, are explained in Attachment "A", which is incorporated into this Agreement by reference. Attachment "A" also explains the financial obligations of Residents whose care is paid for pursuant to the Medicare of Medicaid programs and the services that are covered by those programs. Facility agrees to not enact a change in the charges as listed in Attachment "A" without a thirty (30) day written notice. B. DUE DATES AND OBLIGATION TO PAY TIMEL Y- Facility charges for services provided shall be billed monthly to the Resident. These charges are due and payable fourteen (14) days from receipt of invoice. /f payment is not received by the fourteenth (14th) day after receipt of invoice, the account baiance is considered past due or delinquent, and the Facility may add a late charge to the Resident's account as allowed by law. This late charge shali be assessed on the monthly balance at the lesser of the monthiy rate of 1.5% (one and one-half percent) or the maximum amount permitted by law. This late charge does not alter any obligations of the. Facility or Resident under this Agreement. The Resident recognizes that the Faciiity does not offer credit or accept installment payments. The Facility's acceptance of a partial payment does not limit the Facility's rights under this Agreement. C. FA/LURE TO PAY - If the Resident faiis to make a timely required payment, the Facility may require the Resident to vacate the facility. Faciiity will notify Resident of intent to discharge in accordance witn State and Federal law. D. FEE FOR A RETURNED CHECK - A service fee of $25.00 (twenty five dollars) or the actual fee charged by the bank, whichever is greater, will be charged for any returned check. EXHIBIT Page 1 of 18 I A 3/21/:J.!J03Facility Admission Agreement E. DISCHARGE FOR FAILURE TO PAY - If a Resident is required to vacate for failure to pay, the Facility shall provide advance notice as set forth in the Resident's Rights section of this Agreement of as required under State and Federal law. This notice shall be considered received either on the actual date of receipt or five (5) days after mailing, whichever occurs first. V. RESIDENT'S RIGHTS AND RESPONSIBILITY A. CONSENT FOR TREATMENT 1. NURSING FACILITY SERVICES - By signing this Agreement, the Resident consents to the Facility providing routine nursing and other health care services as directed by the attending physician. From time to time, the Facility may participate in training programs for persons Seeking licensure or certification as health care workers. In the Course of this participation, care may be rendered to the Resident by such trainees under supervision as required by law. Consent to routine nursing care provided by the Facility shall include consent for care by such trainees. 2. PHYSICIAN SERVICES - The Resident acknowledges that he or she is under the medical care of a personal attending physician and that the Facility provides services based on the general and specific instructions of this physician. a. The Resident has a right to select his or her own attending physician. If, however, the Resident does not select an attending physician, or is unable to select and attending physician, an attending physician may be designated by the Facility. The resident's attending physician is responsible for meeting all of the regulations set forth for nursing home care. ATIENDING PHYSICAN: Dr. Hammettt b. The Resident recognizes and agrees that all physicians providing services to the Resident, inciuding those designated by the Facility, are Independent contractors. The Resident recognizes and agrees that such physicians are not associates or agents of the Facility, and that the Facility's liability for any physician's act or omission is limited. B. RESIDENT'S PERSONAL PROPERTY c. The Resident shall be soiely responsible for payment of all charges of any physician who renders care to the Resident in the Facility, uniess the charges are covered by a third party payor. The Faciiity strongly discourages the keeping of valuable jewelry, papers, iarge sums of money, or other items considered of value in the Facility. The Facility shall make reasonable efforts to safeguard the property/vaiuables that the Resident chooses to keep in his or her possession through provision of a locked drawer in the resident's room, if they choose. A safe is availabie in the main office to store items of value. The Resident agrees to inform the Facility of all valuable property upon admission. If, at any time during the Resident's stay, new items of value added to the resident's possessions in the Facility, the Resident aiso agrees to so inform the Facility Administrator or designee. Failure to report that property has been brought to the Facility will exempt the Facility .from responsibility in case of theft. The Viiiage of Laurei Run cannot be responsible for any valuables, money, or damage to personal items I property of Resident. D. RESIDENT'S RECORDS 1. CONFIDENTIALlTY_ Information included in the Resident's medical records Is confidential. Individuals other than the Resident shail not be ailowed to review that Resident's records with the Resident's written consent, except as required or permitted by law. CONSENT TO RELEASE BY FACiliTY - The Resident agrees to disclose information required to provide necessary care according to the specifications set forth in Attachment "B". Page 2 of 18 3/21 121)03Facility Admission Agreement E. RESIDENT RIGHTS- The Resident has certain rights conferred upon him or her by State and Federal law. Such Resident Rights are set forth in Attachments "C" and "D", both of which are incorporated into the Agreement by reference. F. RIGHT TO REFUSE TREATMENT_ The Resident has the right to refuse treatment and to revoke consent for treatment pursuant to applicable state law. The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where. in the opinion of the attending physician or by judgment of a court of law, the Resident is determined to be mentally incompetent to make a decision regarding refusal of treatment, the decision to refuse treatment may be made by a Legai Representative, subject to State and Federal law. Resident has the right to make determinations regarding the care and treatment he or she does or does not want at the end-of-life. This individual right to make such self-determinations is more fully explained in Attachment "E", which is incorporated into this Agreement by reference. G. THE RESIDENT'S DUTIES 1. RESIDENT GRIEVANCES- Residents are urged to bring any grievances concerning the Facility 10 the attention of the Facility Administrator or designee. Residents also have the right to contact the State Facility Licensing agency, the State Long Term Care Ombudsman, or both, to register grievances against the Facility. 2. DIET- The Resident understands that his or her diet is medically prescribed and, therefore, must be monitored by the Facility. The Resident agrees to consult with the Nursing or Dietary staff regarding food or beverages brought into the Facility. 3. MEDICATIONS_No medications or drugs may be brought upon Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. Packaging of medications must be compatible with the Facility's medication distribution system. No drugs of medications may be brought into the Facility unless 1hey are delivered to the nurses' station. 4. CARE OF FACILITY'S PROPERTY_ To preserve the value of the Facility's property for future Residents' use, the Resident agrees to use due care to avoid damaging the Facility's property and premises. The Resident shall be responsible for repair or replacement of the Facility's property damaged or destroyed by the Resident. However, the Resident shall not be responsibie for such damage as is to be expected from ordinary wear and tear. 5. CARE OF THE RESIDENT'S ROOM- The Facility encourages the Resident to have a homelike environment, and will attempt to accommodate all reasonable requests to individualize Resident rooms. For safety reasons, the Facility must approve any addition or rearrangement of furniture, hanging of pictures, posters, or other similar activities. 6. DEATH- In the event of Resident's death, Facility is directed to contact the following funeral home: Fogelsanger-Bricker VII. PERSONAL FUNDS A. The Resident has a right to manage his or her own personal funds. if the Resident wants assistance with management of personal funds, the Facility shall assist if requested to do so in writing by the Resident or Resident's representative. At the Resident's or Resident's representative's written request, the Faciiity shall hold, safeguard, manage, and account for these funds. Such request shall be prepared in accordance with State law. B. Resident personal funds deposited with the Facility shall be handled as set fOI.th in Attachment "F", which is incorporated into this Agreement by reference. Page 3 of 18 3/21/2D03Facility Admission Agreement C. If the Resident does want the Facility's assistance with managing personal funds, the Resident is required to complete and sign the RESIDENT TRUST FUND AUTHORiZATION FORM, which is incorporated into this agreement by reference. VIII. TERMINATION BY AGREEMENT A RIGHT TO TERMINATE. The Facility shall not transfer or evict the Resident solely as a result of the Resident changing his or her manner of payment from Private or Medicare to Medicaid, unless the Facility is not Medicaid certified. 8. RIGHT TO TERMINATE_ The Resident may terminate this Agreement at any time, by notification of intent to discherge made to the social service department, or in their absence, the LPN or RN in charge of the wing residing. Termination will not become effective until RESIDENT has been discharged by RESIDENT'S attending physician. All charges incurred during any stay Covered under this agreement wi/I remain due to the FACILITY. . Against Medical Advice Departure/No Immediate Jeopardy _ RESiDENT has the right to refuse treatment, and leave the property of FACILITY without concurrence by RESIDENT'S attending physician at any time. In such case, the FACILITY, nor the PHYSICIAN take no responsibility in medical condition at time of departure, nor will FACILITY assist in providing medication or arranging services to facilitate the departure. . Against Medical Advice Departurellmmediate Jeopardy _ Should the RESIDENT decide to refuse treatment and depart the FACILITY, and the FACILITY has knowledge that doing so would place the RESIDENT in a position of Immediate Jeopardy, the FACILITY will teke action necessary to prevent harm to the RESIDENT. C. PERSONAL PROPERTY OF RESIDENT UPON DISCHARGE. The Facility shall make reasonable efforts to safeguard the Resident's personal belongings after discharge. The Facility, however, shall not be liable for any damage to or loss of the Resident's property. The Faciiity may dispose of any property left by the Resident if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable State iaw. D. REFUNDS-PRIVATE PAY- If the Resident is discharged before using full.prepaid charges, the Facility shall refund the unused portion of Such charges with a reasonable periOd of time. If the Facility is required by law to hold Resident persons funds in a demand trust account, the balance of these funds shall be refunded promptly after the Resident's date of discharge. E. REFUNDS-MEDICARE/MEDICAID_ If a Resident is retroactively approved for Medicare or Medicaid benefits, previous payments made that will be Covered by the Medicare or Medicaid programs will be refunded promptly in accordance with the Facility's refund policy. Contact the Facility Business Office for details on the refund policy. F. TRANSFERS AND DISCHARGES AND BED HOLDS 1. The Facility shall give notice to the Resident, and if known, a family member, Agent, or Legal Representative of the Resident, of transfer or discharge as foilows: a. Where legally required, this notice shall be given at least thirty (30) days prior to the Resident's transfer or diSCharge. b. In cases where the safety of health of the Resident or other individuais in the Facility may be endangered, or if other legal I'easons exist, notice may be gIven as soon as practicable before transfer or discharge. c. The reason (s) for the transfer/discharge shall be provided at the time of notice of transfer/discharge. d. Notice will include information regarding the right to appeai a transfer/discharge. Page 4 of 18 3/21/2@03Facilit;IAdmission Agreement 2. The Facility shall only transfer or discharge a Resident under the following conditions: a. The transfer/discharge is necessary fO!" the Resident's welfare and the Resident's needs cannot be met in the Facility; b. Tile tl'ansfer/discharge is appropriate because the Resident's heaith has improved sufficiently so the Resident no longer needs the services provided by the Facility; c. The safety of individuais in the Facility is endangered; d. The health of individuals in the Facility would otherwise be endangered; e. The Resident has failed, after reasonabie and appropriate notice, to pay for (or to have paid under Medicare or Medicaid) a stay at the Facility; f. The Facility ceases to operate. 3. The facility shall enforce the following bedhDld policy when a resident is trans~rred for hDspitalization or therapeutic ieave: a. Those residents covered by Medicare at the time of transfer or therapeutic leave will be required to pay privately beginning the day after discharge in order to ensure a bedhold. The bed will be held indefinitely, as long as payment is made. On the day of transfer/leave, the residentlPOA will be notified of the current rate and asked if they wish to have the bed heid. b. Those residents covered by Medical Assistance are permitted a 15-day bedhold by Pennsylvania state regulation. The bed will be held for a maximum of 15 days without cost to the residentlPOA. Beginning on the 16th day, the residentlPOA will be required to pay privately in order to hold the bed for additional time. The bed will be held indefinitely, as long as payment is made. Prior to the end of the 15-day period, the residentlPOA will be notified of the current rate and asked if they wish to hava the bed held. c. Those residents paying privately or who are covered through a different third party payment other than Medicare or Medical Assistance will be required to pay privately beginning the day after discharge. The bed will be held indefinitely, as long as payment is made. On the day of transfer/leave, the residentlPOA will be notified of the current rate and asked if they wish to have the bed held. d. In the event the resident and/or others acting on behalf of the resident choose not to pay to hold a bed as set forth In the paragraphs above (a), (b), and (c), the resident is nevertheless entitled to the next available bed when he/she is ready to return to the facility. IX. ENFORCEMENT OF THIS AGREEMENT A. SOLE AGREEMENT- This Agreement, along with any documents attached or included by reference, Is the only Admission Agreement between the Facility and Parties, except that, Amendments due to changes in State or Federal law or reguiations are automatically deemed to be part of this Agreement. Any other changes to this Agreement are valid only if made in writing and signed by all Parties. If changes in State or Federal law make any part of this Agreement invalid, the remaining terms shall stand as a valid Agreement. B. ATTORNEYS' FEES/COLLECTION AGENCY FEES- In the event the Facility institutes and is a prevailing party in iegal action against any Party to this Agreement, arising from that Party's failure to comply with the terms of the Agreement, the Facility shall. be entitled to receive from the losing Party reasonable attorneys/collection agency fees. C. NON-ASSIGNA.8LE A.GREEMENT_ The Resident agrees that the right of the resident to reside at the Facility is personal and is not assignable. The Resident may not transfer his or her rights under this Agreement to any other person. X. GENERAL PROVISIONS A. WHO IS COVERED BY THE AGREEMENT_ in addition to the Parties signing tllis Agreement, the Agreement shall be binding on the heirs, executors, administrators, distributors, successors, and assigns of said Parties. Page 5 of 18 . 3/21/20G3Facility Admission Agreement That means the Resident's financial obligation to the Facility for the services provided through this Agreement survives the Resident's death, and any remaining charges must be paid from his/her estate. B. WAIVER OF RIGHTS UNDER THIS AGREEMENT_ The failure of any Party to enforce any term of this Agreement or the waiver by any Party of any breach of this Agreement will not prevent the subsequent enforcement of such term, and no Party will be deemed to have waived the right to subsequent enforcement of the Agreement. C. SEVERABILITY OF CERTAIN PROVISIONS_ If any provision in this Agreement is determined to be illegal or unenforceable, then such provision will be deemed amended so as to render it legal and enforceable and to give effect to the Intent of the provision; however, If any provision cannot be amended, It shall be deemed deleted from this Agreement without affecting or impairing any other part of this Agreement. D. GOVERNING lAW- This Agreement Is executed and shall be governed by and construed In accordance with the laws of the state in which Facility is located. E. NOTICES- All notices shall be deemed sufficiently given if maiied to the Resident, Agent, legal Representative and/or Responsible Party, if any, at the address indicated below. Each such person shall be responsible for notifying the Facility in writing of any change of address. In addition, the Faciiity shall notify the person designated by the Resident of any significant change in the Resident's condition as required by law and regulation. By ';Jiirg Below, The Parties Acknowledge Receipt of the Attachments referred to in this Agreement: (INITIAL) The Resident designates the following persons to be notified of any significant change in the Resident's condition: Allent/Leaal Representative/Responsible Partv (Circle One) Name Henry Henson Address (street) 1128 Mainsville Road CitY/State/Zip Shippensburg, PA 17257 Phone (Home) 530-5174 Phone (Work) 514-4731 Reiationship to Resident Son/POA Other Person to be Notified Name Address (street) CitY/State/Zip Phone (Home) Phone (Work) Relationship to Resident Page 6 of 18 3/21/2b03Facifity Admission Agreement ADMISSION AGREEMENT SIGNATURE PAGE Resident Date Witness if Resident Signed with a Mark Date Witness if Resident Signed with a Mark Date I ,/ Legal ~ J , 1'<;),5/0' 0 Date /(17).5'1/)-,2/7/ Legal Representative's Telephone Number Legal Representative's Social Security No. I f7- 3cf~ S-3 <7--J Agent Date Agent's Telephone Number Agent's Sociai Security No. , ~i1 ~;/) 3 Date Page 7 of 18 3/21/2003Facility Adrnission Agreement ATTACHMENT A - Rate Schedule The following is a listing of current charges due for services provided at Laurel Care Nursing and Rehabilitation Center. Changes will not be made to the charges herein without thirty (30) day prior written notice. Room Rate $ 148.00 per day semi -private $ 163.00 per day private Hair Care Transportation Laurel Care Nursing and Rehabilitation Center provides medical transportation services two times per month free of charge for our residents within a fifteen (15) mile radius. Medical Appointments in excess of twice monthly and personal transportation may aiso be arranged for a $25.00 fee. Laurel Care Nursing and Rehabilitation Center offers hair care services that include hall' cuts, perms, and coiors for male and residents. Services are available as posted in the hair salon and at the fee schedule posted. Billing for these services will be included in the monthly statement to resident/responsible Darty. Visitor's Meals Dialysis Transportation - 3x Weekly Dialysis Transportation _ $150.00 /month . Breakfast $4.50 . Lunch $4.50 . Dinner $4.50 Ancillary Charges Meals are available for visitors however, they are to be ordered a day in advance. Prices are: Incontinence Fee Wander guard Bed / Chair Alarm Oxygen Concentrator Use Specialty Overlay Mattress Class A Specialty Bed Medical Supplies $3.00/day $1.00/day $1.00/day $1.00/ day $10.00/ month $5.00 / day Varies by Cost Page 8 of 18 3/21/2()03Facility Admission Agreement ATTACHMENT B - HEALTH INFORMATION DISCLOSURE This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully, RESIDENT NAME: Agatha Haut Laurel Care Nursing and Rehabilitation Center believes in the strict protection and privacy of your medical related information. This Information is always available to you upon request to review. Information about your care and payment for care will only be disclosed only with your approval according to the following guidelines. Unless otherwise stated, disclosure may be made via verbal conversation, telephone conversation, facsimile, modem communications, or cellular communications. I. Treatment A. Internal Access 1. Clinical Operations Laurel Care Nursing and Rehabilitation Center will keep a medical record on the nursing unit in which you reside detailing the current plan of treatment, physician orders, and narrative notes concerning your care. This record is only available to caregivers that are directiy Involved in your care. Any internal service that you agree to receive will enable appropriate staff that provide that service access to your medical record. Examples of internal care providers are employees or facility contracted providers including: . Nursing Staff - Nurse Aides, Licensed Practical Nurses, Registered Nurses, etc. . Sociai Workers & Admission Director . Therapy Staff - as ordered . Clinical Dietician & Dietary management staff . Consultant Pharmacist . Clinical Case Manager . Therapeutic Recreation staff 2. Quality Assurance/Quality Improvement Laurel Care Nursing and Rehabilitation Center routinely reviews the service provided to ensure that we are providing the highest level of service practicable. During such reviews, your medical record may be reviewed by internal staff to ensure that necessary services are provided. Any reporting of findings made to facility management will not Indicate the name of the Individual unless corrective action is required to remedy an individual finding. Examples of quality assuranceiquality Improvement staff may be: . Director of Nursing . Administrator . Regional Quality Assurance Nurse . Medical Director . Medical Records Coordinator . Clinical Case Manager . Quality of Life Director B. External Access Only providers in which you choose to provide services to you who are not a part of the internal operations of Laurel Care Nursing and Rehabilitation Center will be granted access to your medical record. Page 9 of 18 3/21/2<Y03Facility Admission Agreement Examples of external providers are: . Physicians & Designated Physician Office Staff . Behavioral Health Services . Hospital Outpatient Clinics . Laboratory Clinic . X-Ray &ior Other Diagnostic Provider . Dialysis Clinics . Dentists . Optometrists &ior Ophthalmologists . External Caseworker II. Payment Laurel Care Nursing and Rehabilitation Center accepts many forms of insurance to cover the cost of care provided at our facility. Upon your approvai, Laurel Care Nursing and Rehabilitation Center wili disclose only the necessary information to respective payment sources required to receive coverage for service. Failure to approve Laurel Care Nursing and Rehabilitation Center to disclose information to a potential payment source will resuit in a private bill generated to the resident or designated financial manager. Exampies of payment sources may include: . Medicare Intermediary (Veritus) . Medicaid . Adams County Assistance Office . Any Private Insurance Company you designate . Any Managed Care Company you designate . Any financial institution that you have retained to manage financial resources III. Regulatory Agencies Laurel Care Nursing and Rehabilitation Center is a licensed Skilled Nursing Facility, monitored primarily by the Pennsylvania Department of Health Division of Nursing Care Faciiities, and the Division of Safety inspection. Uniess otherwise stated Laurel Care Nursing and Rehabilitation Center reserves the right to comply with ali pertinent regulations in providing access to the medical record and payment information to ail pertinent regulatory bodies Including but not limited to: . Pennsylvania Department of Health . Pennsyivania Department of Public Welfare . Adams County Area Agency on Aging . Pennsylvania Auditor General's Office Health Care Finance Administration Page100f18 3/21/2003Facility Admission Agreement IV. Attestation I fully understand how Laurel Care Nursing and Rehabilitation Center will use and disclose my medical and payment information. I understand that any request, or agreement for service provided as indicates herein enables Laurel Care Nursing and Rehabilitation Center to disclose only the necessary information to required providers/payment sources. I ask that Laurel Care Nursing and Rehabilitation Center adhere to the special Instructions listed here in disclosing' medical and/or payment information: 1'~Ja Cf5....u;ol h~~;;,- I f\6 f""f. iI/1h/Y) ilILf17<<"";r/ 11 /.lid I agree that my rights have been explained to me, and that I understand how to access and approve/disapprove medical disclosure of my personal medical and payment information. Signature of Facility Representative: Date: .1{ J) Jj-~ L--- ]-)..]-01" ~xc1Z~<A'( / .., -.. Signature of Resident/legal Decision Maker: k Date: Page 11 of 18 3/21/2003Facility Admission Agreement ATTACHMENT C - Notice of Residents Riq!:!!2 RESIDENT'S NAME: Agatha Haut 1. Upon admission I was fully informed and will be continually informed during my stay of services available within the facility and of all related charges, including those charges, if any, for services not covered by the basic per diem rate, or of services not covered under the Medicare or Medicaid Programs (Titles XVIII AND XIX of the Social Security Act).. 2. I am being informed of my rights as a resident within this facility and of all rules and regulations governing resident conduct and responsibilities. 3. I may be advised of my medicai condition by my physician (unless medically cDntraindicated and documented in the medical record) and am afforded the opportunity to par\i>:ipate in the planning Df my medical treatment. I may refuse treatment, to the extent permitted by law. 4. I have the right to refuse tD participate in any experimental research, or in the planning of my medicai treatment. 5. I will be transferred or discharged only for medical reasons, for my welfare, for the welfare of the Dther residents, for non-payment of charges, or to be placed In a lesser care placement, if applicable. If I am to be transferred Dr discharged, I will be given reasonable advance notice to insure an Drderly transfer or discharge. 6. Except in a medical emergency, I will not be transferred or discharged, nor shall my treatment be altered radically without consuitation with me, or if I am incompetent, without prior notification of my guardian, next of kin, sponsoring agency, or POA. 7. I will be assisted if necessary to exercise my rights as a resident and as a citizen, and to this end I may voice grievances and recommend changes in policies and services tD facility's staff and/or to Dutside representation of my choice. 8. I will be free frDm restraint, interference, coercion, discriminatiDn, and/or reprisal. a. I may manage my own personal financial affairs. b. If I dD not chDDse to manage my personal financial affairs, or if i am unable to do so, Laurel Care Nursing and Rehabilitation Center will accept responsibility for my financial affairs. If I do not choose to have the facility manage my affairs, I shall designate on a document separate and apart from my Admission Agreement. I further understand that if LCNRC accepts management of my personal affairs, I will be given an accounting of all financial transactions made on my behalf, at least quarterly. c. A written accDunt will be maintained on a current basis with written receipts for all personal possessions and funds I have delivered or deposited with facility and for all expenditures and disbursements made on my behalf. 9. I will be free from mental and physical abuse. I will be free from chemical and (except in emergencies) physical restraints, except as authorized in writing by a physician for a specified and limited period of time Dr when it is necessary to protect me frDm injury to myself or to Dthers. If it is necessary to cDntinue the use of restraints, the physician shall evaluate and document in the medicai record my physical and mental conditiDn and what alternative care or treatment needs are to be prescribed. 10. My personal and medical records are confidential. I may approve or refuse release to any individual outside the facility, except in the case of my transfer to another health care institution or as required by law or third party payment contract. If I apprDve the release of this information, it will be In writing. 11. I will be treated with CDllsideratiDn, respect, and full recognition of my dignity and individuality, including privacy in treatment and in care for my personai needs. 12. I will nDt be required to perfDrm services for the facility that are nDt inciuded for therapeutic PUrpDses in my plan of care and agreed to by me. 13. I will be permitted to assDciate and communicate privately with persons of my choice. I will be permitted 10 send and receive personal mail unopened (uniess medically contraindicated as documented by my physician in the medical recDrd). 14. I will be permitted to participate in sDcial and religious activities, unless medically cDntraindicated. Page 12 of 18 3/21/,e003Facillty Admission Agreement 15. I will be permitted to meet with community groups at my discretion (unless medically contraindicated as documented by my physician in my medicai record). 16. I will be permitted to retain and use my personal clothing and possessions as space permits, uniess to do so would infringe upon the rights of other residents and uniess medically contraindicated as documented by my physician in my medicai record. 17. If I am married, I am assured privacy for visits with my Spouse. If my spouse and I are residents within this facility, we will be offered the opportunity to share the same room as space allows (unless medically contraindicated as documented by the attending physician in the medical record). 18. Mistreatment and abuse are strictly prohibited within this facility. 19. If I have been adjudicated incompetent in accordance with law, if I have been found medically incapable of understanding these rights by my physician, or if I exhibit a communications barrier, then these rights and responsibilities evolve to my guardian, next of kin, sponsoring agency, representative payee, or POA. 20. Suggested visiting hours are 10:00 a.m. to 8:00 p.m. each day. 21. Laurel Care Nursing and Rehabilitation Center will permit members of recognized community organizations and representatives of community iegal service programs whose purposes include rendering assistance without charge to residents to have access to The Village of Laurel Run. 22. Laurel Care Nursing and Rehabilitation Center may limit access where it may be a detriment to resident care and well-being. At no time; however, may they restrict my right to have iegal representation. 23. If Laurel Care Nursing and Rehabilitation Center is closed, they will notify me or my guardian, next of kin, sponsoring agency, representative payee, or POA, in writing of such act in sufficient time for me or them to make alternate arrangements for my transfer and care elsewhere. 24. I further understand that the aforementioned recitation of my rights and responsibilities with Laurel Care Nursing and Rehabilitation Center does not preclude or in any way limit the rights and responsibilities within Laurel Care Nursing and Rehabilitation Center does not preclude or in any way limit the rights and responsibilities assured to me under the Constitution of the United States and the Commonwealth of Pennsylvania. IN WITNESS WHEREOF, I hereby acknowledge that I have read the above and have been fully informed of the contents contained herein on this 23" day of March 2003. Governor's Action Line: 1-800-932-0784 Department of Health: 1-800-692-7254 Adams County Ombudsman: 717-334-9296 Department of Health Harrisburg Field Office: 717-783-3790 Page 13 of 18 ~/2.1/20!J3Facility Admission Agreement ATTACHMENT D - MA 401 Admissions Notice Packet Page 14 of 18 3/2.:l~003Facility Admission Agreement ATTACHMENT E - Advanced Directives Resident Name: Agatha Haut ACKNOWLEDGEMENT OF RECEIPT OF ADVANCE DIRECTIVE INFORMATION I have been notified of my right to refuse treatment, to make decisions regarding medical care, and to execute any advance directive, if I so choose. I understand that the execution of an advance directive is not required for admission to, or for a continued stay at Laurel Care Nursing and Rehabilitation Center. I have been given a copy of the Laurel Care Nursing and Rehabilitation Center policy regarding impiementation of the Patient Self-Determination Act, general information about advance directives, and of the applicable State law; I will be given the opportunity to discuss any additional questions and/or concerns regarding advance directives at tile initial care plan meeting. Resident Responsible Partyt I LCNRC Representative, Date Date 3 j..j9..J~ 3 Date ,l;:J; 34,;;; For Office Use Only Opportunity for executing advance directive was offered on 3/19/2003. Resident named above has: )c- chosen not to execute an Advance Directive at this time. remains uncertain about executing an Advance Directive. - copy of living will provided at admission. Other comments: .' E_.../ .--/- /. - '/;/d::l~k.z~ A ai/[tJ0 Jd M/t.td-CfI. /CO ~et!~~ cL "uw7j.a't:O, _ , LCNRC R~resentative l /, ~ &' Date: .J~~j 3 Page 15 of 18 . 3/21/2003Facility Admission Agreement ATTACHMENT E-1 - Cardiopulmonary Resuscitation All residents in long term care facilities have rights guaranteed to them under Federal and State Law. Inciuded in these rights is the right to accept or refuse treatment, including cardiopulmonary resuscitation (CPR). At this time, of my own free wiil, I am exercising this right by declaring the following: I authorize CPR to be administered ~, do not authorized CPR to be administered Resident Signature: Date: If Resident is incapable of signing: Resident Representative Signature:.x' Status or Type of Representation Jin ,II~ 7/ w'm~.m",dA.1 ~1"/&J jfj} !k ~ --.. Date: <JJ, 2.I'~3 Date: :J'~..1j;3 , , Page 16 of 18 3t21/2003Facility Admission Agreement ATTACHMENT F - Management of Residents Funds AUTHORIZATION FOR MANAGEMENT OF RESIDENT'S FUNDS I, Henry Henson for Agatha Haut, hereby authorize the Laurel Care Nursing and Rehabilitation Center to manage and account for all my personal funds. I understand that a full and complete separate accounting of all financial transactions made on my behalf will be maintained and made available to me and/or my Power-of-Attorney at least quarteriy and upon request. I understand that my personal funds will be placed in the interest bearing "Patient Holding Account" which contains only monies of other nursing home residents, and which is maintained separately and distinctly from all faciiity funds. Interest earned on this account will be credited to my account monthly. However, residents receiving Medical Assistance benefits must use earned interest towards cost of care. I understand that withdrawals of more than $50.00 will require at least 48 hours advance notice and will be in the form of a check. I understand that I or my Power-of-Attorney can arrange for deposits and/or withdrawals from my account by contacting the Chief Financial Officer Monday-Friday between 8 AM and 4 PM. ATTACHMENT F-1 - Authorization for Payment of Medicare Benefits I, Henry Henson for Agatha Haut, certify that the information given me In applying for payment under Title Xiii of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration or its intermediaries or carriers any information concerning this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payable for physician services to the physician and/or authorize such physician or organization to submit a claim to Medicare or any other secondary insurances for payment to me. ATTACHMENT G - Transmission of MDS Information MDS INFORMATION It is necessary for providers of Medicare and Medicaid services to inform our residents and/or responsible party about the automation and electronic transmission of resident information. Each resident will have an assessment done by Laurel Care Nursing and Rehabilitation Center staff regarding physical, social, mental, recreational, rehabilitative" and dietary status on an ongoing basis during Ilis/her stay at this facility. This information is placed in a format called the MDS, or Minimum Data Set. This information is electronically transmitted to the State and the Federal Government to be used for survey, reimbursement, and health data collection reasons. Attached to this form is a complete explanation regarding WllO has the legal right to access this information. Laurel Care Nursing and Rehabilitation Center want you to be aware of the fact that the assessment is done, that it is electronically transmitted, and is accessible to other parties as noted on the attached information sheet. Signature on this form serves as an acknowledgment that you have received the attached information sheet regarding the Electronic Transmission of the MDS and the resident information contained on that form.. Please feel free to discuss any questions you may have with the Administration at Laurel Care Nursing and Rehabilitation Center. Page 17 of 18 .. 3/21/2003Facility Admission Agreement ATTACHMENT F - Management of Residents Funds AUTHORIZATION FOR MANAGEMENT OF RESIDENT'S FUNDS I, Henry Henson for Agatha Haut, hareby authorize the Laurel Care NUrsing and Rehabilitation Center to manage and account for all my personal funds. I understand that a full and complete separate accounting of all financial transactions made on my behalf will be maintained and made available to me and/or my Power-of-Attorney at least quarterly and upon request. I understand that my personal funds will be placed in the interest bearing "Patient Holding Account" which contains only monies of other nursing home residents, and which is maintained separately and distinctly from all facility funds. Interest earned on this account will be credited to my account monthly. However, residents receiving Medical Assistance benefits must use earned interest towards cost of care. I understand that withdrawals of more than $50.00 will require at least 48 hours advance notice and will be in the form of a check. I understand that I or my Power-of-Attorney can arrange for deposits and/or withdrawals from my account by contacting the Chief Financial Officer Monday-Friday between 8 AM and 4 PM. ATTACHMENT F-1 - Authorization for Payment of Medicare Benefits I, Henry Henson for Agatha Haut, certify that the information given me in applying for payment under Title X111 of the Social Security Act is correct. I authorize any holder of medical or other information about me to release to the Health Care Financing Administration or its intermediaries or carriers any Information concerning this or a related Medicare claim. I request that payment of authorized benefits be made on my behalf. I assign the benefits payabie for physician services to the physician and/or authorize such physician or organization to submit a claim to Medicare or any other secondary insurances for payment to me. ATTACHMENT G - Transmission of MDS Information MDS INFORMATION It is necessary for providers of Medicare and Medicaid services to inform our residents and/or responsible party about the automation and electronic transmission of resident information. Each resident will have an assessment done by Laurel Care Nursing and Rehabilitation Center staff regarding physical, social, mental, recreational, rehabilitative" and dietary status on an ongoing basis during his/her stay at this facility. This information is pi aced in a format called the MDS, or Minimum Data Set. This information is eiectronlcally transmitted to the State and the Federal Government to be used for survey, reimbursement, and health data collection reasons. Attached to this form is a complete explanation regarding who has the iegal right to access this information. Laurel Care Nursing and Rehabilitation Center want you to be aware of the fact that the assessment is done, that it is electronically transmitted, and is accessible to other parties as noted on the attached information sheet. Signature on this form sarves as an acknowledgment that you have received the attached information sheet regarding the Electronic Transmission of the MDS and the resident Information contained on that form.. Please feel free to discuss any questions you may have with the Administration at Laurei Care Nursing and Rehabilitation Center. Page 17 of 18 3li1/2Q.03Facility Admission Agreement ATTACHMENT H - Pharmacy Choice Resident Name: Agatha Haut Patient #: 2034 Pharmacy Selection Policy Policy: Residents of Leurel Care Nursing and Rehabilitation Center haye a right to choose their pharmacy provider. Laurel Care Nursing and Rehabilitation Center must ensure that medications are avaiiable in a timeiy manner, are accurately dispensed and administered, and are packaged in a facility specific format. Laurel Care Nursing and Rehabilitation Center contracts with Diamond Pharmacy for resident medications. Residents/Responsible Parties who prefer a different provider may select another pharmacy, as iong as that pharmacy can provide the seNice specific to Laurel Care Nursing and Rehabilitation Center policy. [8] I wish to utilize Diamonds Pharmacy for provision of medications. o Other Pharmacy: ATTACHMENT 1- Activity Permission Waiver I, Henry Henson for Agatha Haut, hereby request to participate in fieid trips, as physical status permits. ATTACHMENT J - Authorization for Photographs I, Henry Henson for Agatha Haut, hereby authorize the facility personnel to take the following designated photographs. (Check One) 1. Photographs for Identification x Yes 0 No 2. Photographs of Medical Conditions x Yes 0 No (Example: pressure areas) These photographs are utilized to provide documentation of a medical condition, are viewed only by professionals, and are placed in the resident's medical record) 3. Photographs and Name for Public Relations ~Yes 0 No (Example: attendance at an activity) These photographs and names may appear in a newspaper or flyer, or videotape may be taped at a public function. Page 18 of 18 04/21/2005 08:38 71 73522142 VILLAGE OF LAUREL RN PAGE 02 ooolis18 Laurel Care Nursing and1.Rehab 6375 Charnbersburg RQad , Fayetteville Ph -7222 page# 1 Admission Pate: 03/26/2003 Discharge Date, 11/26/2004 Statement Date, 04/01/2005 , II 1 I APRIL 2005 BILLING HENRY "H2UJl<:" HENSON 1128 MAINSVILLE ROAn I IFI YOU HAVE QUESTIONS CALL SHIPPENSBURG PA l7f57 I JANICE STAMBAUGH AT 1(717) 352-2721 EXT. 211 DUE PPON RECEIPT LATE 4/16/05 i Date Description 1 I Units Ref# Amcunt , 71,499,45 PREVIOOS BALANc~ I i I . , JPAST DUB P' EASE REMIT I I I I : : , ENDING BALANCE :i I n,499.45 .w. -.. -. _~.. _,b_.. _0. '~__h U.h.h .. - - Send To: ..... 'Pl'~'asr- 'i-;;;;;::--Of"i"h;d"R:emIt"ThiS--'po;::tioii,'lWTtil"iou;:'--i?aiffli,;'nt'.......-......-..............-.---.- Resident jj: 000002034 . I I I Resident Name: HAUT AGATHA R Statement Date, 04/01/2005 I I I 'toea1 J!.:moun1: :Due: 73..1499.45 I I Total Amount Paid: I Laurel Care Nursing a~d Rehah 6375 Chamhereburg Roa~ Fayetteville Pj 17222 EXHIBIT ! B FROM :WOLFTAS . FAX NO. :7172459661 Jun. 06 2005 10:30AM P5 .. Tax Map: 02-20-1800-087 Il"4l ~M\1..^ ~ L. THIS INDENTURE I Made the lYih day of E::J;n J..Q JLt' Between ,2003, AGATHA HAUT, single, of 1128 Mainsville Road, Shippensburg, Pennsylvania 17257-----------..._____ ----------------.---------------------------------------- (hereinafter called the Grantor), of the one part, And IlENRY D, HENSON, SR., single, of 1128 Mainsville Road, Shippensburg, Pennsylvania 17257-------- -----------------------._m___________...________n.__...____- (hereinafter called the Grantee), of the other .. ~art, Witnesseth, that the said Grantor for and in consideration of the sum of One (51.00) Dollar lawful money of the United States of America, unto her well and truly paid by the said Grantee, at or before the sealing and delivery hereof, the receipt whereof is hereby acknowledged, has granted, bargained and sold, released and confirmed, and by these presents do grant, bargain and sell, release lU1d confmn unto the said Grantee, his heirs and assigns, in fee simple, ALL the following described real e.'ltate lying and being situate in the Borough of Carlisle, Cumberland County, Pennsylvania, bounded and described in accordance with the plan of property by Larry V. Neidlinger, R. S., dated October 9, 1985, and descnl1ed as follows: BEGINNING at a point on the eastern line of North Bedford Street at line of property now or formerly of Robert Ege; thence along the same and through a partition wall dividing Nos. 537 ... and 541 North Bedford Street, South 60 degrees 00 minutes East 150.00 feet to an unnamed alley; :1 .. tl)ence along said alley, South 30 degJ:eeS 00 minutes West 22.50 feet to a point at property now or formerly of Mary R. Cornman; thence along: the same, North 60 degrees 00 minutes West 150.00 feet to a point on the eastern line of North Bedford Street; thence along the same, North 30 degrees 00 minutes East 22.50 feet to a point, the place of beginning. BEING improved with a two story frame dwelling and a two story frame shed in the rear known and numbered as 537 North Bedford Street, Carlisle, Pennsylvania 17013. TfIR ABOVE DRSCRIBED REAL ESTATE is the Same which Carol J. Fleming by deed dated October 22, 1992 and recorded in the Office of the Recorder of Deeds of Cumberland County, Pennsylvania in Deed Book Y, Volume 35, Page 547 conveyed unto Agatha Haut, the Grantor herein. EXHIBIT ~oo~ 255 "J.~,3982 I'.' ;~" I~ ; ~ i I c. , .-.'.------..-. FROM :WOLFTRS FRX NO. :7172459661 Jun. 06 2005 10:30RM P6 tj.:: I-,r THIS IS A TRANSFER FROM MOTHER 1'0 SON AND IS EXEMPT FROM TRANSFER TAX. SUBJECT to all conditions, easements, restrictions, and reservations of record. And the said Grantor, for herself and her heirs, executors and administrBtOlll, do, by these presents, covenant, grmt Imd agree, to and with the said Grantee, his heirs and assigns, that she, the said Grantor, and her hei\1l, all and singular the hereditaments and premises herein described IlIId granted, or mentioned and intended so to be, with the appurtenances, unto the said Grantee, his heirs and assigns, against her, the said Grlmtor, and her heirs, and against all and every other person and persons whosoever lawfully claiming or to claim the same or any part thereof, by, from or under him, her. it, or any of them, shall and will Specially Warrant and Forever Defend. In Witness Whereof. the party of the first part has hereunto set her hand and seal. year first above written, Dated the day and 1~, Sealed and Delivered ~ "'_"" >R"""'" OF U" . :M~cA0[J1fl 1M) ~~~. Ag bit Hau' o W. ." (,~~ I..,'.. r'n nl >.J r:c :'Z:J:J.~ 'I ,.... ., ...- )> CI , c.c ~,." .'-1 . {SEATg :' l:J ("') AI: ,....~ :::a 0 m c: 0 (.-) ~ ,2: r'rT r~" -. rl1 r-," .... """< C.? -J.; c..,:) r (').. ., Gommonwealth of Pennsylvania County of Franklin : ss On this the m day of Ub(UQ f'1~,.. - 2003, before me, a Notary Public for the Conunonwealth of Pennsylvania, residing in the Cou:n~ undersiBned Officer, personally Agatha Haut, Imown to me (or satisfactorily proven) to be the person whose name is subflcribed to the within instrument, and acknowledged that she execuled the same for the purposes therein contained. IN WITNESS WHEREOF, I hereunto set my hand and official seal. \ f \)\'l\~.lI'tJ',,, I. ,...,'\~O N I'."', . .' - ,b #~ ~ ~...... ' "'f "1'-:,. I~i,.. ,.,""~',.f ,J ..',..~A . (;().;":~ .'%. ~. ',~ 'f~"~ Il~~~~' -....... r ~~ ~ '. j :;.! ..~.<l :~i'; ':i: ~ ",: ;: ..' .: -= :~ ."...... .. ~ ";I' ,,'.... '':o~ ,"'" " / ~""''j. ,....., . ,;.i.~... '~', .,~ 't;~ ~. .:'':1. ..' ..J.'" -::r.',,~i<.1I:'~;' , "''1: '" """ ".1 '..", .,.,.~. -.' '. -'" ....2'4 '1>:,.- -I.,~ . ':;. .~, . ..........--~,,~ .,....... .~"" O1l0"..," ", #"fJt...",I...C.... cA. . d IJ';/ ~ 11-,~ ,.. -4..1 "Ad Notary Pu ic My commission el\pires .t"-' BOOk 255 PACE3983 FW)M : WOLFTAS l'~ 'it !.~ 'f i ,i, I,: '! II , ! ~ . I! FAX NO. :7172459661 Jun. 06 2005 10:30AM P7 ','i The address of the above-named Grantee is: 537 North Bedford Street Carlisle, P A 17013 ,,', ~'4 /J.l/.t.~.L_ On behalf of the Grante ,,'\'.d..- I ....l'I.'I' "'.1'1' :", ,." '",''''' ">j"d " "." l . , ..,\ I...... "... In CUl1liH.:l'land COUnty P A \-~Q-~ ~r-- . . Recorder of Deeds eOOk 255 PACE39B4 .. ',. '."'-"'-...,., -~.._".,~- 05/15/2005 01:50 71 72580852 TRI COUNTY ABSTRACT PAGE 02 FacetW.i:n SeraGn Print for rae-deeds, fro#L I'CAMA_Login" 6/14/2005 9: 3:1: 08 Alrl NEIGHBORHOOD: 200 CUMBERLAND COUNTY ASSESSMENr OFFICE 2004 BASEYEAR CONTROL # 02000093 DISTRICT: 02 - CARLISLE BORO 1ST ~D SD. I I [Short Neune ILAS'l: NAME I FIRST NAME [C/O NAME IADDRESS:1- IADDREBS2 I~OBT OFFICE, IS:l'ATE " ZIP: I HENSON. HENRY D SR HENSON IIElH'.X 0 3 PARCEL: 02-20-1800-087. I SPEC ID: LOT: L--.-, Tbaclt: SR PROPER:l'Y TYPE. R 537 NORTH BEDFORD STREET SALES DEED BK/pG.....00255-03982 DATE OF SALE...02/1912003 SELLING PRICE: 1 CARLJ:SLE PA 170:1-3 Situs: 537 N BEDFORD STREET I CURUN"l' VALUES I Prop Descrip. : J AasQssQd Fair Market L, LAND DEBC: LAND LESS THAN 1 ACU FMV - 75110 L - 15460 I LAND USE TYPE' 101 C&G - B - 59650 I DEEDED ACRES. .OB approved? -> :l' - 75110 I Screen 1 NWllbe" -Switch Down Arrow ~Naxt Enter Selection > Screens, X MExit, J -Jump ModQ, Entry, up Arrow -Previous Entry, Record: F -ll'orms~ I ? -Screens, 6SS8S ... Image B ...Browse EXHIBIT I D ~ ~ U) U( ....... ....... D ~ ~ -u IN fC ~J 12 "I-- ~ N \t G ~ ,. n i' :: ~:j -< r--.,) ":.:.:,j .... .~;:) <:...,-1 o .n -< I-n n-;;.:;::: '~ ~3 C) ..-~] r) !~::di-n ~ ::< c_ c::: r~"" N \7 {;":') f',.,) .. ."y .. G) Andrew J_ Benchuff, Esquire Kornfield & Benchoft~ LLP Attorney for Plaintiff 17 North Church Street Waynesboro, PA 11268 (117) 762-R222 FAX 762-6544 andrew{Q)komfield.net Atty. LD. 89\59 PINEY PARTNERS, LP., tJdfbJa LAUREL CARE NURSING AND REHABILITATION CENTER, Plaintiff IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT, PA v. CUMBERLAND COUNTY BRANCH AGATHA HAUT and HENRY HENSON, SR, CIVIL ACTION - LAW NO. 2005- 35;(.1 CiUitT~ Defendants PLAINTIFF'S PRAECIPE FOR LIS PENDENS AGAINST DEFENDANTS TO THE PROTHONOTARY: Kindly enter the above-captioned matter as a lis pendens against Agatha Haut and Henry Henson and real property known as 537 North Bedford Road in the Borough of Carlisle, Cumberland County, Pennsylvania described by deed to Henry Henson, Sr., recorded in the Office of the Recorder of Deeds of Cumberland County, in Deed Book Y, Volume 35, Page 547. Date: July 11, 2005 ~ ~ 9 ~ ...{) c C) - -:) ,..., () " -...) = w = -<1 oJ' ~ W r- ,- ::::! }J c,: r\1~ I-~'- -'OM (fl. ~ N -cJY ~ c), _1':> ~ :!:~1 :?'C"j " CSll1 , <t.' --;> ~.-\ ...~ ;~ f''' :-.n ...z '-< - A,\LEGALI7\CowdML.doc IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT, PA CUMBERLAND COUNTY BRANCH CIVIL ACTION - LAW PINEY PARTNERS, L.P., t/dIb/a LAUREL CARE NURSING AND REHABILITATION CENTER, Plaintiff Defendants ) ) ) ) ) ) ) ) ) ) No. 2005-3527 vs. AGATHA HAUT and HENRY HENSON, SR., ANSWER TO COMPLAINT Filed on behalf of Defendants, Agatha Haut and Henry Henson, Sr. Counsel of Record for this party: JON M. LE'WlS 205 Coulter Building 231 South Main Street Greensburg, PA 15601 PA ill. No. 16,337 724-836-4730 A:UGA.U'1\Htn3oofuulAnswerlbComplllint.doc IN TIIE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT, PA CUMBERLAND COUNTY BRANCH CIVIL ACTION - LAW PINEY PARTNERS, LP., t/d!b/a LAUREL CARE NURSING AND REHABILITATION CENTER, Plaintiff Defendants ) ) ) ) ) ) ) ) ) ) No. 2005-3527 vs. AGATHA HAUT and HENRY HENSON, SR., ANSWER TO COMPLAINT AND NOW, comes the above named Defendants, by and through their counsel, JON M. LEWIS, ESQUIRE, and respectfully makes this Answer to Complaint and avers as follows: 1. Admitted. 2. Admitted. 3. Admitted. 4. Admitted. COUNT I 5. Admitted in part and denied in part. The contract, as it is signed, speaks for itself. The rest is denied. However, at the time the Defendant Agatha Haut went into the facility, she was on Medicare, She was promised medical assistance by Plaintiff. Henry Henson, Sr. filled out the papers with the Plaintiff to obtain the medical assistance. Unfortunately, it is averred and believed that the Plaintiff held the agreement until February 2004 with the result that, notwithstanding their promise to the Defendant, Agatha Haut, there was a failure to submit the bills to Medicaid or medical assistance, which would have paid the bills. Therefore, the Facility Agreement is only a portion of the agreements between 1 .....\LEG...LI'1\HtI\1lCIDHmnA.nowrl'lOComplllinl.doc the parties, The first was the oral promise that the bi\1s would be submitted to Medicaid/Medicare andJor medical assistance. 5. Admitted in part and denied in part. The said Henry Henson, Sr., provided the Plaintiff with a Power of Attorney showing that he could sign as her representative. He did not sign on his own as a responsible party to obligate himself to the bi\1s. 6. Admitted in part and denied in part. It is admitted the bi\1 was received. However, it is denied that Henry Henson, Sf. is responsible for the bi\1. He never agreed to that. It is further averred that that sum is not due the Plaintiff because the Plaintiff promised to submit the bi\1s to MedicarelMedicaid at the time of the signing ofthe contract, Exhibit "A", and failed to do so. The Plaintiff told the Defendants that there was no need to submit pharmacy bi\1s or pharmacy prescriptions to the VA since the Defendant was entitled to the free medicine. They made that statement because they told the Defendants that MedicaidJmedica1 assistance would pay. 7. Denied. Neither Defendants owe the Plaintiff any money. The bills should have been submitted to MedicarelMedicaid andJor medical assistance as they Wl:re the primary obligors and would have been if the proper application was made or should have been made. The Defendants aver and believe that neither would have gone into the Plaintiffs facility if they had been told that MedicareIMedicaid would not be paying for it. Neither would have the money to pay for the expenses. 8. Admitted. WHEREFORE, Defendants pray your Honorable Court grant judgment in their favor and against the Plaintiff with interest and costs of suit. COUNT II 9. Answered previously. 10. Admitted in part and denied in part, At the time of the transfer of the real estate, the Defendant, Henry D. Henson, Sr., borrowed $49,900.00 from the Patriot Federal Credit Union to make 2 A:\LECAU7\Hwson'HmnAnswatoComplllint.doc that purchase as the Plaintiffs well know. The mortgage was dated February 14,2003. The consideration for transfer was $49,900.00. Out of that $49,900.00, the said Defendlmt, Agatha Haut, received the proceeds. A true and correct copy of the settlement sheet is attached hereto, made a part hereof and marked Exhibit "1 ", By reviewing Exhibit "1 ", one can observe the following payoffs including ABN AMRO Mortgage Group, HomeEq second mortgage, Chambersburg Hospital, County taxes, judgment owed to U.S. Clerk of Courts, etc., as well as closing costs. All those obligations were those of Agatha HauL At closing, she received $17,279.36. Out of that amount, she paid other bi\1s, expenses and distributions as she desired. 12. Denied. The house was worth $54,000.00. The Defendant had sold the property for $54,000.00. That is the actual value of the property prior to the Complaint of Plaintiffs. A Sales Agreement had been executed and a sale had originally been schedul,~d for September 1". 13. Denied. This was a sale for value even though Henry Henson, Sr. is the son of Agatha HauL 14. Admitted. At the time of the sale the house was a substantial portion of Agatha Haut's assets. 15. Denied. Agatha Haut was not insolvent at the time ofthe sale. She received $17,279.36 at time of sale plus she also received Social Security and a V A pension. This settlement was 2-14-03. She was not in a nursing home on 2-14-03 and was in generally good health on that date. 16. Admitted. 17. Denied. The transfer was made of the property because the Defendant, Agatha Haut, had numerous debts and obligations to payoff. Her son, Henry Henson, Sr. bought the house from her and obtained a mortgage so he could pay off the debts and give Agatha Haut the $17,279.36 balance that she wanted. This was done while she was in good mind and good health. Thus, both 17(A) and (B) are answered in that there was no attempt to hinder, delay or default any creditor because money was used to 3 A,\LEGAL\ 71HwsoofunnAnsw<<toComplaiot.doc pay the creditors and there was equivalent value for the property. The house is only worth $54,000.00 today. WHEREFORE, Defendants pray your Honorable Court grant judgment in their favor and against the Plaintiff with interest and costs of suit. J . LEWIS, ESQUIRE Attorney for Defendants 205 Coulter Building 231 South Main Street Cireensburg"Pl\ 15601 724-836-4730 P l\ rd. No. ][6,337 4 SETILEMENT STATEMENT . Optional FOlllllor U.S. DEl'ARTMENT OF I-JOUSING AND URBAN DEVELOPMENT File Number: FTA7824 Loan Number: FINAL Trano'llc\ionswitho\lt5el\ers OMB Approval No. 2502-0491 Mtg. Ins. Case Number: NAME OF BORROWER: Henry D. Henson, Sr. ADDRESS: 1128 MainsvilLe Road, Shi.ppem.burg, PA 17257 NAME OF LENDER: Patriot Federal Credit Union ADDRESS: 800 Wayne Avenue, Chall1bersburg, PA 17201 PROPERTY ADDRESS: 537 North Bedford Street, Carlisle, PA 17013 Carlisle borough SETTLEMENT AGENT' nanKlm 1'-" ~efVlces ana Aostracllng LO., 1eJepnone: I 1 I-L04-jL~U ~ax: 11 I-L04-1"", PLACE OF SETTLEMENT: Chal11bersb\.ug, PA 1720J LoallNumbet.., SEllLEMENT DATE: 021\ 4/2003 L. SetllemenlCharaes M.DisbursementloOlhers 800. Items Pavable In Connectionwilh loan 1501.?ayolf:OOD0833615 ~7, 613 .16 801. LoanOrl InallonFe...O.OOO%to to ABN AMRO MortllaQe Grollo, Inc. 602. Loan Discount 0.000% to 1502.Pavoff:0081032195 6,045.77 803. AppraIsal Fee to HomE.n Ser~lcJnn Corooration 8ll4. CreclitReDort 1503. R05. Lllnd\"!r'sll1soectlon ree 1106. MorlQaoeAoolicatlon Fee 1504. 807.AssllmotionF(le 80a.FJoodCert.toPatriotFederaICreditUnJon P.O.C.19.50 1505. B09.A IicaUonfeetoPatriotfederalCreditUnJon P.O.C.75.00 810. 1508. 811. 900. Items Required by Lender to be Paid in Advance 1507. 901. Interest Frorn 02/14120G3 to OJ/011201l3 Ull$ oerdav 902. Mortgage Insurance Pn'mium fOf \0 1508. 90J.HazardlnsurancePremiumforlo 1509. 904. 1510. 1000. Reserves DeDDsited with Lender 1001.Hazardlns\lranc&!T1o.@$oermonth 1511. '002. MOf\O:!.< e Insu!:!lnee mo. filI$ oermontn 1003. City Property Taxes mo.liil$ per month 1512. 1004. County Property Taxes mo. @$ per month 1005. SchooJ Taxes mo. ilil$ ner month 1513. 1000. mo. r1il$ ermonth 1007. rno.ail$ oer month 1514. 1008.mo.l1il$ ermonth 1100.1i\le Chames 1515. 1101. Selllement or closlnn fee to FrallkJin Real EstaleServices 100.00 1102.. Abstraclor title S\"!illfcn 1516. 1103. Tltle examlnalion 10 FrankUn Real Estate Services 175.00 1104.TilJelnsuranceblntler 1511. 1105. DocumentProoaralion 1106.Notar Fees 10 Robin M. Ml,.IlI 10.00 1518. 1107. Attorney's fees 10 Franklin Real Eslate Services 50.00 includuaboveilemsNo.\ 1519. 1108. Tlllo Insurance Includes aboye Items No.1 1520. TOTAi_ DISBURSED 23,658.93 1109. Lel\der'scolierage $4'J,1l00.o0- lenleronline1603) 1110. Owner's covera~e$- 1111. 1112. 1113. 1200. Governmenl Recordino and Transfer Charoes 1201. Recordll1(! Fees Deed $38.50; MOrl(!age $3B.50; ReVe:lQ~. 38.50 38.50 N. NET SETTLEMENT 1202. Ci\'llICo\lntv 1a)l.Jstamos Deed $' Morloaae $ 1203. State Tax/stamps DeedS' Mort a e$ 1600. Laan Amount 49,900.00 1204. 1205. 1601. PLUS C:l.shICheck from Borrower 0.00 1300. Addilional SettlementCharoes 1301.S\lrvev 1602. MINUS Totlll SeUlement Chargee 8,961.71 1302.Pestlnsneclion 11I1'10'14001 1303. Express Mail to Franklin ReaJEstaleServices 30.00 1603. MJNUS Total Disbursements to Others 23,658.93 1J04.PavmenttoChambersbur Has ital 2.935.00 f1ine'15201 n05. 2003 Ccu"t'l Tnes to Oarltme Mover, Tax Collector :nO.71 1306.JudomentPavmenlto U.S. Clerk of Courl 5,312.50 16ll4. EQUALS Dlsburse!T1ents to Borrower 17,279.36 1307. {atterexplratlonotanyappJlcable 13ll8. rescls.slonpllrlodrequlredbylaw) 1400. Total SetUemenl CharQes (enter on Hne 1602) 8,961.71 ~~b~e':;:~~I~~II~ 'ii:~"s~~rt l~~ rl~~~:'~:~\~:~~: f;,aal::::;~l.~"e~l~ ~~~~~~ll~~ H~~~1"A~edJ'I:~~~N~~~':~~t lrue Ind accurale '1O'lemenl of all racelplll and dlsl>ursemem. made ,'" my accounl Henry The HUD.1A A:\FORMSSIVerification,doc VERIFICATION I, Hemry Henson, Sr. , state that I am the Defendant in the foregoing action and as such verify that the facts set forth in the Answer to ComD1aint are true and correct to the best of my knowledge, information and belief and understand that thisVerification is made subject to the penalties of I 8 Pa.C.S.A. Section 4904 relating to unsworn falsifications to authorities, ~~~ ~ Dated: August 10, 2005 ~~~ -,< '<l ~ :;.1'. t:? o .p ~ ..... ~~ -fi I'D _\,0 U). ~_4 t;( ~~ ,-:,-,~(, -,~rn :~ ~ ~ 9- ~~- \4;;"\' ,../ .;;;. '3- ~ cT> (~~'t 1,,-:"'-' -- (j\ SHERIFF'S RETURN - REGULAR ~~~~ CASE NO: 2005-00157 T hoo:>- 35'.J 1 /' COMMONWEALTH OF PENNSYLVANIA: COUNTY OF FRANKLIN PINEY PARTNERS, L.P. ET AL VS AGATHA HAUT ET AL GUS ALEX IOU , Deputy Sheriff of FRANKLIN County, Pennsylvania, who being duly sworn according to law, says, the within NOTICE OF COMPLAINT AND rI.J 5 fJ~Vj)i!.N.s was served upon AGATHA HAUT the DEFENDANT , at 1044:00 Hour, on the 29th day of July , 2005 at 1128 MAINSVILLE ROAD SHIPPENSBURG, PA 17257 by handing to AGATHA HUT a true and attested copy of NOTICE OF COMPLAINT AND together with LIS PENDENS and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge .00 .00 .00 .00 .00 .00 So ~s~~ GUS ALEX IOU By ~f(~ 09/21/2005 KORNFIELD AND BENCHOFF Sworn and Subscribed to before )./ day of NotariaI:>eaI I Ri'honl D. Moe."y. NoIory !>ubli, ChambersJ:xu:g Booo, hankljn CoWdy ~_~y com~l~~oo E~Pi'=~~~~ me A.r UG-~L c. SHERIFF'S RETURN - REGULAR jJn-,,,.......d'J-<C CASE NO: 2005-00157 T "71:- 0 $- 35.11 COMMONWEALTH OF PENNSYLVANIA: COUNTY OF FRANKLIN PINEY PARTNERS, L.P. ET AL VS AGATHA HAUT ET AL GUS ALEXIOU Deputy Sheriff of FRANKLIN County, Pennsylvania, who being duly sworn according to law, NO'Ttce Or (!O,q-PLAcNI A-ov.b says, the within LIS PENDENS was served upon HENRY HENSON, SR the DEFENDANT , at 1044:00 Hour, on the 29th day of July 2005 at 1128 MAINSVILLE ROAD SHIPPENSBURG, PA 17257 by handing to HENRY HENSON SR NonCE O~ {J,"'J'lA<,v r Fffv,P a true and attested copy of LIS PENDENS together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge .00 .00 .00 .00 .00 .00 So Answers: _ p.;.v ..;ZI...- ~ GUS ALEXIOU BY/~ '1. Sheriff 09/21/2005 KORNFIELD AND BENCHOFF Sworn and Subscribed to before me this ~I day of ~oo ~ A.D. '.' Uc~.:- . j(!~4 i Notary I' . Notaria1;:,~J Richard D. McCarty, Notary Pt!blj~ Chambersburg Boro, F),mk]in County My Commissioo E"pir" !~, ~9, ::'()(1"> o ~;. r~ "" = = "'" V"' ,..,.., -0 o -n :J:!-n P'lE:. -,,:-,~ ~_ {J '"'~' ~~~~; ~;~-~ (,) o ::~ ~~~ f~ ~~'~ ?q ... N 10/19/2005 WED ]A: 21 FAX I4J 003/009 Andtew 1. BenchoJT, E!iqulrc Komtlcld & Benchon~ LLP Attorney for Plainliff 17 Nonh Church Streer Wllyncsboro, P,\ 17268 (717) 762-nn FAX 762-6544 anclrcw0)kornlic\d,M,[ Atty. 1.0. ROIS9 PINEY PARTNERS, LP., tldfb!a LAUREL CARE NURSING AND REHABILlT A nON CENTER, Plaintiff IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT, PA v. CUMBERLAND COUNTY BRANCH AGATHA HAUT and HENRY HENSON, SR., CIVIL ACTION - LAW Defendants NO. 2005.3527 JOINT PRAECIPE TO MARK CASE SETTLED AND DISCONTINUED BETWEEN TIlE PARTIES AND PLAINTIFF'S PRAECIPE TO MARK LIS PENDENS WITHDRAWN TO THE CUMBERLAND COUNTY PROTHONOTARY: Kindly mark the above-captioned matter settled and discontinued pursuanllo the attached Joint Stipulation, Agreement and Release between the Parties. Kindly mark the praecipe filed in the above-captioned matter withdrawn by Plaintiff, Date: /0 /1)27 ( } n M. Lewis. Esq. Attorney for Defendants Date: /")' ,~ / /17('---' ,t>" '/ ,....,.... 10/19/2005"..1,:1.: 21 FAX I4J 004/009 , Anc!rcw J. Bcnchotr. Esquire Korntleld & BCllChoft: LLI) Attorney for Ptatm\fl 17 North Church Street Wl1yntsoOr(l. j)A 1726R (711)762-8222 FAX 762.6544 i1ndrew@!.kornlidd.l1l::l My. !.D. 89159 PfNEY PARTNERS, L.P., tJd1b/a LAUREL CARE NURSING AND REHABILITATION CENTER, Plaintiff IN THE COURT OF COMMON PLEAS OF THE 9TH JUDICIAL DISTRICT, PA v. CUMBERLAND COUNTY BRANCH AGATHA HAUT and HENRY HENSON, SR, CIVIL ACTION. LAW Defendants NO. 2005-3527 JOINT STIPULATION, AGREEMENT AND RELEASE This Stipulation, Agreement and Release (hereinafter refen'ed to as "the Agreement") is entered into by and among Piney "Partners, 1.1'" t/d/b/a/ Laurel Care Nursing and Rehabilitation Center, (hereinafter referred to as "Laurel Care") and Agatha Haut and Henry Henson, Sr., (hereinafter referred to as "Haut and Henson") in connection with any and all claims relating to a cerlain dispute between Laurel Care and HaUl and Henson, as more particularly described in the above-captioned matter (hereinafter referred to as "the Action"), or otherwise. The Parties to the above-captioned matter and this Agreement are Laurel Carc, Haut, her successors, administrators and/or executors, and Henson. Laurel Care operates a nursing and rehabilitation center located at 63 7S Chambersburg Road, Fayetteville, Adams Count)', Pennsylvania. Agatha HauL was aresident at Laurel Care based on a Facility Admission Agreement between the parties dated March 22, 2003, and Laurel Care supplied nursing and medical care to Agatha Haut 1 10/19/200,5 :;8" 1..: 21 FAX ~ 005/009 '. on open account as part of the Facility Admission Agreement. Henry Henson, Sr., Agatha Haut's SOn, admitted Agatha Haut into Laurel Care by signing the Facility Admission Agreement as Agatha Haut's agent/legal representative/responsible party. Prior to admission into Laurel Care, and on or about February 14, 2003, Agatha Haut purportedly transferred property lying and being situate in the l3orough of Carlislc, Cwnberland County, Pennsylvania, to Henry Henson, Sr., said property being more particularly described in the Cumberland County Recorder of Deeds Office at Deed Book 225, Page 3982, and known as 537 NOrth Bedford Street, Carlisle, PA 17013, tor no or nominal consideration. Laurel Care filed a Complaint against Agatha Haut and Henry Henson on or about July 12, 2005, in the above-captioned matter, alleging breach of contract for nonpayment of amounts owing under the Facility Admission Agreement and fraudulent conveyance of the North Bedtbrd Stn:et property. On or about July 12, 2005, Laurel Care filed Plaintiff's Praecipe for Lis Pendens Against Haut and Henson to list the above-captioned matter as a lis pendens against the North Bedford Street propcrty. Thereafter, Agatha Haut and Henry Henson filed an Answcr to Complaint denying the claims of Laurel Care. Haut and Henson through counsel also alleged improper care ofIIaut by Laurel Care and threatened a malpractice negligence claim for thc alleged improper care. On or abO\lt September 24, 2005 Haut died at her residence known as \ 128 Mainsville Road, Shippensburg, Pennsylvania 17257. To date, an Estate has not been opcned for Haut in Franklin and/or Cumberland County as 2 10/19/2005, ~Bn 1,(.:21 FAX I4J 006/009 her legal representative(s) have represented to Laurel Care and its legal representatives that there is no Estate and/or any Estate would be insolvent. Settlement on 537 North Bedford Street, Carlisle, PA 17013, is scheduled fOT October 25, 2005 at 11:00 a.m. in the law office of Duncan & Hartman, P.C (hereinafter referred to as the "Settlement Agent")_ The real estate is to be conveyed from HenSOI} to Nathan Stoner of S4 7 North Bedford Strect, Ca\'lisle, P A 17013, a disinterested third-party for an arm's length consideration of $54,000.00. At settlement, the following payoffs will be made by Henson: $46,375.63 to Patriot Federal Credit Union, $3050 to Patriot Federal Credit Union, $1,357.71 to the Cumberland County Tax Claim Bureau, approximately $750.00 in current taxes to the County, Borough and Carlisle School District, and fees, if any, to file the Joint Praecipe directing the Prothonotary to mark the case settled and discontinued between the parties and Plaintiff s Praecipe to mark the lis pendens withdrawn, for total payoffs in the approximate amount of$48,S13.84. At all times relevant to this Agreement, Laurel Care was and is represented in this Action by Andrew J. Bellchoff, Esquire, Kornfield & Benchoff, LLP, 17 North Church Street, Waynesboro, PA 17268. At all times relevant to this Agreement, Hau~ her successors, administrators and/or executors and Henson were and are represented in this Action by Jon M, Lewis, Esquire, 205 Coulter Building, 231 South Main Street, Greensburg, PA 15601-3115. For and in consideration of the recitals which are incorporated herein and the promises and mutual undertakings herein contained, and other good and valuable consideration, the receipt of which is hereby acknowledged, Laurel Care and Halli and Henson (hereinafter collectively referred ~ ~ 10/19/2005, ~D 1''.: 21 FAX i4l 007 /009 to as "the Parties"), intending to be legally bound hereby agree as follows: I. Henson's proceeds from Settlement, minus payoffs, in the approximate amount of $5,486.16, shall be paid directly to Andrew J, Benchoff, Esquire, Attorney for Pincy Partners, L.P., t/d/b/a Laurel Care Nursing and Rehabilitation Center, in cash or certified fWlds by the Settlement Agent. 2. At Settlement, and along with this fully executed Agreement, the Parties shall deliver a signed Joint Praecipe directing the Prothonotary to mark the Action settled and discontinued and Plaintiffs Praecipe directing the Prothonotary to mark the lis pendens withdrawn to the Settlement Agent for filing. 3. Fulfillment of the promises and mutual undertakings herein contained shall reprcsent payment in full for all money and non-economic damages or relief, in whatever form. that the Parties ate demanding from each other in the Action, or may demand from each other in any other Action, including but not limited to, compensatory damages, incidental and consequential damages, punitive damages, attorney fees, and costs. The Palties agree that each will pay their own attorney fces and expenses incurred prior to the effective datc of this Agreement and thereafter. 4. The Parties on behalfofthemse1ves, their successors and assigns hereby fully release and forever dischargc one another, their successors and assigns [Tom all manner of liability and all a.ctions, suits, debts, dues, accounts, bonds, covenants, contracts, agreements, judgments, claims and demands whatsoever in law or in equity arising out of the facts alleged in the Action or otherwise except with respect to fulfillment of the promises and mutual undertakings of this Agreement. 4 1011.9/2005, !F;Jl l.A,:21 FAX !OJ 008/009 ." .. 5. The Parties have entered into this Agreement after consultation with their attorneys and intend to be legally bound thereby. The Parties further represent that the purpose and effect of each provision of this Agreement has been fully explained to them, that they understand the contents and meaning thereof, and that they execute this Agreement as their own free act and intending to be legally bound hereby. The Parties hereby declare and represent that no promise, inducement or agreement not herein expressed has been made to them, that this Agreement contains the entire agreement and that the terms of this Agreement are contractual and are not a mere recital. 6_ Each party hereto has made such investigation of the facts pertaining to this Agreement and of all the matters pertaining thereto as it deems necessary and neither Party relies upon any promise or representation by any other Party, or by any of ticer, agent, employee, representative Or attorney of the other Party with respect to any such matter_ 7. The Parties have entered into this Agreement to avoid the time and expense associated with litigating the Action and to resolve the litigation through a negotiated outcome rather than a judicial disposition. The Parties agree that they have denied and continue to deny any liability or wrongdoing with respect to the facts and allegations stated and claimed by the other Pmty in the Action, as set forth in this Agreement or otherwise. The Parties n1rther agree tlJ.at under no circlUTISlanCeS shall this Agreement be construed as an admission of liability or wrongdoing by any of the Parties. 5 101J.9/200541!Jl' 1..'.: 21 FAX @J009/009 .... ,~c 8. The Parties agree that the termS and conditions of this Agreement and the disposition, resolution, and terms of this Agreement shall be filed of record in the a.bove- captioncd matter. This Agreement may be used as evidence in any subsequent proceeding in which either ofthe Parties alleges a breach of the Agreement. Should either party be found to be in breach of the Agreement, for whatever reason, the prevailing Party shall be entitled to attorney fees, 9. This Agreement shall bind and inure to the Parties, their successors, administrators, executors and assigns. ;c; Jl IN WITNESS WHEREOF, we ha.ve hereunto set our hands and seals this ..LL- day of U C "06<-{2005 WITNESS: PINEY PARTNERS, L.P., tJdIb/a LAUREL CARE NURSING AND REHABILlT AnON FACILITY /O/zJ;;~- By CJn(L~ --p S-Kc'~~o/zl/or / /, ' C-// ip/I-k . He nson, Sr. . i / , . ! / L/ 6 n , (.,. -j\ -;, . SHERIFF'S RETURN - OUT OF COUNTY CASE NO: 2005-03527 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND PINEY PARTNERS L P ET AL VS HAUT AGATHA 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: HAUT AGATHA but was unable to locate Her in his bailiwick. He therefore deputized the sheriff of FRANKLIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On November 15th, 2005 , this office was in receipt of the attached return from FRANKLIN Sheriff's Costs: Docketing Out of County Surcharge Dep Franklin Co Postage 18.00 9.00 10.00 150.00 .74 187.74 11/15/2005 KORNFIELD & ~ So answe:s~,/ /~~- .< - .-" ;7""" /::-~(/( R. th~mas Kline- Sheriff of Cumberland County BENCHOFF Sworn and subscribed to before me this JJ.J day of7~ ,)iJ'(J:>/ a.D., ~._ ~~~~ In The Court of Common Pleas of Cumberland County, Pennsylvania Piney Partners LP t/d/b/a Laurel Care Nursing & Rehabilitation Center VS. Agatha Haut et al SERVE: Agatha Haut NO. 05-3527 civil Now, July 13, 2005 , I, SHERIFF OF CUMBERLAND COUNTY, PA, do hereby deputize the Sheriff of FrAnkl in County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. ~/?./ ~' '~~"'~""'-<?.{~.R Sheriff of Cumberland County, P A Affidavit of Service Now, ~<..iUf 2r 20 IJJ- at /() "iN o'clock /I M. served the '-' within ((~ (JENDEf-.fS upon ,4GAn4.11 IH+I.I( at 1128 hj4.rtV.rv'IL-<.-~;2.v ~f'(JFN'SISi.J.e-6{ PA '7:>--"-7 by handing to 1+ G A n+r4 ;J A-u '( a T!2UE/ ,4~~.iJ copy of the original -6..5 f't'r-Ju-L- and made known to /.4... the contents thereof. So answers, ~CC~ Uj PA : (1'1 :}c~c~ ~d~ 'j) ef' Sheriff of County, P A COSTS SERVICE MILEAGE AFFIDAVIT $ Sworn and subscribed before me this ~ day of JULy , 20 u ~ . ""jh~CL~ l h<JJ.Jbcrsburg Boro, Franklin County J\ly CommissiM E'Ti~;:0 .... 29, :"007 f $ SHERIFF'S RETURN - OUT OF COUNTY . CASE NO: 2005-03527 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND PINEY PARTNERS L P ET AL VS HAUT AGATHA 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: HENSON HENRY SR 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 November 15th, 2005 , this office was in receipt of the attached return from FRANKLIN Sheriff's Costs: Docketing Out of County Surcharge 6.00 .00 10.00 .00 .00 16.00 11/15/2005 KORNFIELD & So answers:.. ?' .~-- .- . .;..?r'::s~;__~// R. Thomas Kline Sheriff of Cumberland County BENCHOFF Sworn and subscribed to before me this "//...r day of 7~ J~: f!~~ry . , . In The Court of Common Pleas of Cumberland County, Pennsylvania Piney Partners LP t/d/b/a Laurel Care Nursing & Rehabilitation Center VS. Agatha Haut et al SERVE: Henry Henson Sr. No. 05-3527 civil Now, July 13, 2005 , I, SHERIFF OF CUMBERLAND COUNTY, P A, do hereby deputize the Sheriff of Frnnkl in County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. ~~~~~ Sheriff of Cumberland County, PA Affidavit of Service Now, J- u'L Y 2-1 ,20 (,)~ , at /(J)tlc( o'clock Ii M. served the within r/Jr; fENf>ffNS flf'Nl2-y iJEN~t)l,r. S'L ((2~ m~(N..sY(LLU P-:v ~ FJP~,.Js'JSv/2.-6-, j)p /72...).-7 upon at by handing to ;JENI!-y Ikf\l~ON, S;e., a T(2ue! /l17CS:tij) copy of the original JJ's Pf'N}.E:fV-S and made known to /4 the contents thereof. So answers, /I' f)A' ~LlA-A--. t{j r20 . I-f, "f. L 6--<tfl.l.c.;.. : ~~~ f:xzt. Sheriff of . County, P A COSTS SERVICE MILEAGE AFFIDAVIT $ Sworn and subscribed before me this ~ day of J l.!.C' r- ". \ RKhMd D. McCarry. Now:i Pub ie i ,'hambersburg Bolo. FraakhnCounty , \1y Commissicm Expires.. 29, 2007 L_-___ $