The URL can be used to link to this page

Home My WebLink About05-4126IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, 1000 Claremont Road Carlisle, PA 17013 Plaintiff, V. No. OS -Ill'? 1? LAURIE C. WELLER, 108 May Drive, Apt. #1 Camp Hill, PA 17011 Defendant. CIVIL ACTION - LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Lawyers Reference Service Cumberland County Bar Association 2 Liberty Ave. Carlisle, PA 17013 (717) 249-3166 98270 AVISO USTED HA SIDO DEMANDADOJA EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veinte (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objecciones a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacibn o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted puede perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO O BAJO COSTO A PERSONAS QUE CUALIFICAN. Lawyers Reference Service Cumberland County Bar Association 2 Liberty Ave. Carlisle, PA 17013 (717) 249-3166 98270 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, 1000 Claremont Road Carlisle, PA 17013 Plaintiff, V. No. Us - ghat, l_lUt(„?? LAURIE C. WELLER, 108 May Drive, Apt. #1 Camp Hill, PA 17011 Defendant. CIVIL ACTION - LAW COMPLAINT AND NOW, COMES, Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center ("Claremont"), by and through its attorneys, Latsha Davis Yohe & McKenna, P.C., and files the within Complaint against Defendant, Laurie Weller, and in support thereof, avers as follows: 1. Plaintiff, County of Cumberland, Claremont Nursing and Rehabilitation Center (hereinafter "Claremont"), is a county long-term skilled nursing care facility whose offices are located at 1000 Claremont Road, Carlisle, Cumberland County, Pennsylvania. 2. Plaintiff Claremont provides medically necessary nursing services to the citizens of the Commonwealth. 98270 3. Defendant, Laurie C. Weller (hereinafter "Weller'), is an adult individual currently residing at 108 May Drive, Apt. #1, Camp Hill, Cumberland County, Pennsylvania. 4. Defendant Weller is the daughter, and was the attorney-in-fact and person responsible for the financial affairs of Joanne Cooper, deceased. A true and correct copy of Defendant Weller's Power of Attorney is attached hereto as Exhibit "A." 5. Joanne Cooper was admitted on January 22, 2004 to Plaintiff Claremont's nursing care facility. 6. On or about January 22, 2004, Plaintiff Claremont and Joanne Cooper, by and through her attorney-in-fact Defendant Weller, entered into an Admission Agreement ("Agreement"), whereby Plaintiff Claremont agreed to accept Joanne Cooper as a resident at Plaintiff Claremont's nursing care facility and to provide her living accommodations, dietary services, medication/ pharmacy services, and general nursing and medical care, in exchange for a promise to pay for these items and services. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "B" and made a part hereof. Pursuant to the Admission Agreement, Defendant Weller agreed to be Joanne Cooper's Responsible Party. 8. As the Responsible Party for Joanne Cooper, Defendant Weller, agreed, among other things, to perform Joanne Cooper's duties pursuant to the Agreement, namely to use Joanne Cooper's assets and/or resources to compensate Plaintiff Claremont for the nursing care and services which it provided to Joanne Cooper and to make an application for Medical Assistance benefits on behalf of Joanne Cooper. 9. As Joanne Coopers attorney-in-fact and Responsible Party, Defendant Weller had a duty to use Joanne Cooper's assets and/or resources to keep her account current. 10. Defendant Weller failed to use Joanne Cooper's assets and/or resources to pay Plaintiff Claremont for the nursing care and services which Joanne Cooper received at Plaintiff Claremont's nursing care facility. 11. Upon information and belief, instead of using Joanne Cooper's assets and/or resources to keep her account current with Plaintiff Claremont, Defendant Weller converted and/or transferred Joanne Cooper's assets and/or resources to herself and/or others. 12. Upon information and belief, Joanne Cooper possessed assets and received monthly social security and/or pension income in the amount sufficient to pay some or all of the outstanding changes on the account. A true and correct copy of Joanne Cooper's Admission Application, which lists her assets and income, is attached hereto as Exhibit "C." 13. Upon information and belief, Defendant Weller received Joanne Cooper's monthly social security checks and/or pension checks. 14. Defendant Weller failed to make a Medical Assistance application, and failed to respond to multiple requests from the Cumberland County Assistance Office and Plaintiff Claremont to provide verification of Joanne Cooper's income and assets. 3 True and correct copies of the various benefit rejection notices and correspondence from Claremont are attached hereto as Exhibit "D." 11 Joanne Cooper died on December 26, 2004, and as of the drafting of this Complaint, no estate has been opened. 16. As a result of Defendant Weller's failure to pay Plaintiff Claremont for the nursing care and services which it rendered to Joanne Cooper, an outstanding balance accrued and became due and owing in the amount $69,010. A true and correct copy of the monthly invoices is attached hereto as Exhibit "E" and made a part hereof. COUNT I - BREACH OF CONTRACT 17. Paragraphs 1 through 16 above are incorporated herein by reference as if fully set forth at length. 18. Joanne Cooper, by and through her attorney-in-fact Defendant Weller, entered into an Admission Agreement with Plaintiff Claremont as more fully set forth above. See Exhibit "B". 19. Plaintiff Claremont provided nursing care and services to Joanne Cooper pursuant to the aforementioned Agreement from January 22, 2004 through December 26, 2004. 20. Claremont has never received payment for the nursing care services it provided to Joanne Cooper. 21. Joanne Cooper's account balance remains unpaid, despite repeated demands for payment. 4 22. Defendant Welter's failure to keep Joanne Cooper's account with Plaintiff Claremont current from Joanne Cooper's resources and failure to assist in the preparation, completion, and submission of a Medical Assistance application constitute a breach of the Agreement. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Weller in the amount of $69,010 plus interest, together with any other relief the Court may deem just and equitable. COUNT II - QUANTUM MERUIT 23. Paragraphs 1 through 22 above are incorporated herein by reference as if fully set forth at length, 24. Plaintiff Claremont has demanded payment in full from Defendant Weller for the nursing care and services which it provided to Joanne Cooper, and has not received payment for the same. 25. To the extent Defendant Weller received Joanne Cooper's assets and/or income and has failed to pay for the care and services rendered by Plaintiff Claremont from the same, Defendant Weller has been justly enriched. 26. Plaintiff Claremont is entitled to receive payment for the reasonable value of the nursing care and services provided to Joanne Cooper. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Weller in the amount of $69,010 plus interest, together with any other relief the Court may deem just and equitable. COUNT III - BREACH OF FIDUCIARY DUTY 27. Paragraphs 1 through 26 above are incorporated herein by reference as if fully set forth at length. 28. Defendant Weller, at all times material to this cause of action, represented herself to be Joanne Cooper's attorney-in-fact and person responsible for her financial affairs. 29. Defendant Weller, at all times material to this cause of action, acted as Joanne Cooper's attorney-in-fact and person responsible for her financial affairs in dealing with Plaintiff Claremont. 30. As Joanne Cooper's attorney-in-fact and person responsible for her financial affairs, Defendant Weller had a fiduciary duty to Joanne Cooper, to which Plaintiff Claremont is a beneficial party, to ensure that Joanne Cooper's account with Plaintiff Claremont is kept current by using Joanne Cooper's assets and/or resources to pay Plaintiff Claremont for the nursing care and services that it rendered to Joanne Cooper. 31. Defendant Weller breached her fiduciary duties owed to Joanne Cooper, to which Plaintiff Claremont is a beneficial party, by failing to use Joanne Cooper's assets and/ or resources to keep Joanne Cooper's account with Plaintiff Claremont current, and, instead, converting and/or fraudulently transferring Joanne Cooper's assets and/or resources to herself or others. 31 As a direct result of Defendant Weller's breach of her fiduciary duties, Plaintiff Claremont, as Joanne Cooper's primary care giver, the entity responsible for her day-to-day care, and the beneficiary of the fiduciary duty owed by Defendant Weller to her mother, has incurred damages as more fully set forth above. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Weller in the amount of $69,010 plus interest, together with any other relief the Court may deem just and equitable. COUNT IV - CONVERSION 33. Paragraphs 1 through 32 above are incorporated herein by reference as if fully set forth at length. 34. Upon information and belief, Defendant Weller converted, misappropriated and deprived Joanne Cooper of her right in, use and/or possession of her property as more fully set forth above. 35. To the extent Defendant Weller's conversion, misappropriation and deprivation of Joanne Cooper's right in, use and/or possession of the aforementioned property was for the purpose of hindering or delaying their transfer to Plaintiff Claremont, these actions were beyond Defendant Weller's authority as Joanne Cooper's attorney-in-fact. 36. As a result of the foregoing unlawful actions of Defendant Weller, Plaintiff Claremont has incurred damages as more fully set forth above. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Weller in the amount of $69,010 plus interest, together with any other relief the Court may deem just and equitable. 7 COUNT V - FRAUDULENT TRANSFER 37. Paragraphs 1 through 36 above are incorporated herein by reference as if fully set forth at length. 38. Upon information and belief, Joanne Cooper, either on her own or by and through her attorney-in-fact Defendant Weller, transferred her assets and/or resources without receiving reasonably equivalent value and/or for the purpose of hindering and delaying their transfer to Plaintiff Claremont. 39. Upon information and belief, Defendant Weller accepted the transfer(s) of Joanne Cooper's assets and/or resources with full knowledge that the transfer was not for reasonably equivalent value and/or that the purpose of the transfer was to avoid paying Plaintiff Claremont for the nursing care and services that it has rendered to Joanne Cooper. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Weller in the amount of $69,010 plus interest, together with any other relief the Court may deem just and equitable. COUNT VI - EQUITABLE SUPPORT 40. Paragraphs 1 through 39 above are incorporated herein by reference as if fully set forth at length. 41. Upon information and belief, Defendant Weller transferred Joanne Cooper's assets to herself or otherwise misappropriated said assets. 42. Upon information and belief, the above-referenced transfer and/or misappropriation of assets rendered Joanne Cooper indigent and unable to pay the outstanding balance owed on her account. 43. Pursuant to 62 P.S. § 1973, the children of indigent parents have an obligation to support their parents. 44. Defendant Weller is Joanne Coopers daughter. 45. As a result of Defendant Weller's transfer or misappropriation of her mother's assets, Defendant Weller had the ability to satisfy her mother's debt to Claremont. 46. To the extent that Defendant transferred, received or otherwise misappropriated her mother's assets and failed to pay for her care, Defendant violated 62 P.S. § 1973. WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Weller in the amount of $69,010 plus interest, together with any other relief the Court may deem just and equitable. Respectfully submitted, LATSHA DAVIS YOHE & McKENNA, P.C. Dated: 9. // o)p0 r By: Kimber L. Latsha, Esq. Attorney I.D. No. 32934 Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 (717) 620-2424 Attorneys for Plaintiff, County of Cumberland, Claremont Nursing & Rehabilitation Center 10 VERIFICATION I, Mary Kimmel, hereby verify that I am the Finance Manager for County of Cumberland, Claremont Nursing & Rehabilitation Center; that I am authorized to make the within Verification; and the statements of fact in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: z?i4 7'( v Q"'4 7/ Mary me POWER OF ATTORNEY I, Joanne K. Cooper, of 113 May Drive, Apartment 1, Camp Hill, Cumberland County, Pennsylvania 17011, do hereby make, constitute and appoint my Daughter, Laurie C. Weller, of 108 May Drive, Apartment 1, Camp Hill, Cumberland County, Pennsylvania 17011 as my true and lawful Power of Attorney, under the terms and conditions and with the powers and authority contained herein. My intention in granting this Appointment of Power of Attorney is for this individual to have all power and authority to act for and on my behalf with regard to each and every aspect of my financial affairs, unless specifically restricted as set forth below, and this Appointment is to be interpreted to carry out this intention. My attorney's powers and authorities include, but are not limited to the following: 1. PROPERTY - power and authority to convey, and mortgage or pledge real or income producing or not, for cash or title to property in my name if my att to execute, acknowledge and deliver releases, satisfactions, and any relating to real or personal property considers necessary and proper; manage, sell, buy, personal property, on credit, to take Drney thinks proper, deeds, mortgages, other instruments which my attorney 2. INSURANCE - to Dlace and effect insurance, (life, accident, or health), to borrow against, to change the beneficiary of, and otherwise take such steps as are deemed by my attorney as necessary or appropriate as to handle such insurance; 3. CHECK}:NG ACCOUNTS, SAFETY DEPOSIT BOX - ;:o endorse all checks and drafts made payable to my order, and collect the proceeds, to enter and remove from any safety deposit box or boxes that are standing in my name any items, to sign my name for checks on all accounts standing in my name, to withdraw funds from said accounts and to open accounts either in my attorney's name or in my name as attorney in fact; 4. CLAIMS - to collect, compromise and receive all sums of money, dividends, interest, payments on account of debts, and legacies on all property now due or which may hereafter become due and owing to me, or claims made RECEIVED Page 1 of 5 FEB 11 2J05 FISCAL DEPAR'nMENT rNRC ii against me, and to give good and valid receipts and discharges for such payments; 5. SECURITIES - to sell, assign, and transfer stocks and bonds and securities standing in my name at such prices and on such terms as shall seem reasonable to my attorney; 6. BORROWING - to borrow money, and to pledge or mortgage therefor any property, real or personal, which I may own, to make payments and expenditures as may, for the purposes of investment, re-investment, raising necessary funds, or otherwise, be necessary in connection with any of the foregoing matters or with the administration of my affairs; 7. AGENTS, LITIGATION - to retain counsel, agents, and attorneys on my behalf and/or appear for me in any action in which I may be a party or my interest affected, and prosecute, defend, or settle any claims; 8. GIFTS, TRUSTS - to make gifts, whether absolute, contingent, or in trust, and in such amounts, to such persons, including the donee hereof, despite the obvious conflict of interest thereof, and on such terms and conditions as my attorney deems appropriate, including power to distribute assets to any inter vivos trust, and power to create a trust for my benefit and to make additions to an existing trusts for my benefit; 9. BONDS - to act in my behalf in all transactions necessary for the purchase of certain issues of United States Treasury bonds redeemable at par in payment of Federal estate taxes levied upon my estate; 10. EXPENSES - to incur for me, and pay, frot,i my assets, any necessary and appropriate expenses, to support me in the style to which I have become accustomed, and to use assets of mine for maintaining the standard of living of my spouse, children, and any other dependents, and my attorney shall not be required to incur any such expense personally; 11. RETIREMENT PLANS - to do all acts necessary to contribute to or withdraw assets from any retirement plan, or otherwise act in connection therewith; 12. FORGIVE DEBTS - to forgive debts; Page 2 of 5 13. MAKE ELECTIONS - to make such elections and disclaimers in connection with any matter to the same extent as we could if present, including the power to claim an elective share of the estate of my deceased spouse and to disclaim any interest in property; 14. MEDICAL POWERS - to authorize my admission to a medical or nursing residence or similar facility, to enter into agreements for my care, and to authorize medical and surgical procedures; 15. TAXES - to prepare, execute, and file all income tax, gift tax, social security or unemployment insurance and information returns required by the laws of the United States, or of any state or subdivision thereof, to confer with revenue agents, to prepare, execute, and file refund claims, to collect any tax refunds from the United States or any state or subdivision, to execute agreements extending the statute of limitations, to represent me or obtain representation for me before the Tax Court of the United States or any other court in connection with any tax matters, and to do anything whatsoever requisite or necessary in connection with all income tax, gift tax, social security and unemployment insurance taxes required by the laws of the United States or any state or subdivision that I could do in my own Derson; 16 MANAGING BUSINESS - to manage, control, and take charge of any business which I own or in which I have an interest, and to do everything necessary to carry on and continue the affairs of the business including the purchase of materials and supplies, the hiring and firing of Dersonnel, the acceptance of orders for and delivery of merchandise and goods produced, either in cash or for credit, the acceptance of checks, notes, or documents of title in connection with the operation of the business, and the making, issuance, endorsing of any checks, notes, or documents of title as may be necessary in the judgment of my attorney-in-fact; 17. MISCELLANEOUS - to renounce fiduciary positions, to withdraw and receive the income or corpus of a trust; 18. GENERAL - to do all those things which I might do with any property, whether real of personal, and not to be limited in my attorney's power and authority to act for me to those powers enumerated herein. Page 3 of 5 Provided, however, that this appointment of attorney shall be in full force and effect until revoked in writing by Donor. And be it further provided that my attorney shall not be permitted to transfer the authority to carry out my affairs to any other individual or institution without my express, written consent. And be it further provided that my attorney shall not be permitted to disclose any information regarding my financial affairs to Steven R. Weller. This Appointment of Attorney shall not be affected by my subsequent disability or incapacity, it being my intention that this Appointment of Attorney shall survive me, such disability or incapacity, and shall be exercisable notwithstanding such disability or incapacity. The grant of any invalid power hereunder shall not affect any other power hereunder. The following is a specimen signature of the person to whom this Appointment of Attorney is given. r i URIE C. WELLER I, JOANNE K. COOPER, ha ye set my hand and seal hereto, this /01" day of - /I C 1998, intending to be legally bound hereby. JOANNE K. COOPER j! I/ We have witnessed the signature to this Appointment of Attorney: Page 4 of 5 COMMONWEALTH OF PENNSYLVANIA SS: COUNTY OF CUMBERLAND /J On this the ?? day of 1998, before me, a Notary Public in and for said Commnwealth and County, the undersigned officer, personally appeared JOANNE K. COOPER, known to me (or satisfactorily proven) to be the person whose name is subscribed to the within instrument, and acknowledged that he executed the same for the purposes therein contained, and desired the same to be recorded as such. WITNESS WHEREOF, I have hereunto set my hand and Nota?'?aj--Sp`ga Notarial Seal Matthew J. Eshelman, Notary Publi6 Camp Hill Boro, Cumberland County My Commission Expires Nov. 15, 1999 Member, Pennsylvania Association of tdo+ rr: Page 5 of 5 V lit ttr?i1? ?Q,? O ?? 17- Pvehabilitation Center- ADMISSION AGRFFMFNT 1000 Claremont Road Carlisle. PA 17013-8805 main (717) 243-2031 fax (717) 240-1952 As part of admission to Claremont Nursing and Rehabilitation Center, the Resident and the Responsible Party assisting the resident acknowledge and agree to the following: If Claremont Nursing and Rehabilitation Center determines that the Resident is not appropriate or does not qualify for nursing home care, the Resident will discharge from Claremont Nursing and Rehabilitation Center following a 30 day notification of the need to make alternate living arrangements. 2. If the Resident cannot qualify for coverage under the Medical Assistance or Medicare programs, the Resident will pay daily rate for care at the nursing facility. 3. The Responsible Parry (guarantor) assures that the Resident's bill will be paid from the Resident's assets/funds. If the Resident does not have personal funds or when personal funds are exhausted, the Responsible Party will make application to Medical Assistance on behalf of the Resident. If the Resident does not qualify for Medical Assistance-funding, the Responsible Party will arrange discharge for the Resident if the bill is not paid in a timely manner. 4. The Resident authorizes Claremont Nursing and Rehabilitation Center to release information concerning their assets, real or personal, to the Cumberland County Board of Assistance. 5. If the Resident is being covered by the Medical Assistance Program, the Resident and Responsible Party recognize that all income the Resident receives during the month of admission, must be paid to the Claremont Nursing and Rehabilitation Center, regardless of the day of admission, unless waived by the Cumberland County Board of Assistance. The Resident and Responsible Party acknowledge that all future income received by the Resident, while covered under the Medical Assistance Program, must be paid to Claremont Nursing and Rehabilitation Center. Income not applied to charges for care will be placed in the Resident Guest Fund or refunded. 71sF1YirF np-FriPU nft•unJ,,.4,..._f n......... 0/'?? o Date - aa. O Date Date Date T ont ?w-se?? ?rehabilitation Center- APPLICANT FULL NA PERMANENT ADORE TELEPHONE # 7/7_ BIWM DATE f. 7A- MARITAL STATUS DID APPLICANT OR S NAME OF VETERAN 1S THE APPLICANT A PP IMARY FAMILY a eit, Narrg and lation Address SE OND RY CO '1 Name and Relationshi Address P VE IN PERSON: 1000 Claremont Road Carlisle, PA 1 70 1 3-8805 main (717) 243-2031 fax (717) 240-1952 SOCIALSEC'U t # .5 RELIGION /r _ Fix-nCeA"2z YO SPOUSE NAME lroen?s[ti TARY? 1-&- BRANCH- i! hus6Q.-d cal- 5gv - 7oso 71.3- 0943 Home Telephone # 7G3- 7//7 Work Telephone # CA14 014.,% Cdl-.512-01/-7 # ork Telephone APPLICANT HAVEA LEGAL and POWER-OF-ATTORNEY? N TYPE OF NURSING HOME ADMISSION ANTICIPATED: LONG TERM CARE Y SHORT TERM REHAB IS APPLICANTH?QQSPITALIZED PRESENTLY? ADMISSION DATE HOSPITAL jr,?, t? y.,- SOCIAL WORKER PHYSICIAN TELEPHONE # `7 G 3 - 2 2 YR APPLICATION PAGE 2 LIST OTHER HOSPITAL AND NURSING HOME STAYS N THE LAST 60 DAYS: fi b DOES THE APPLICANT HAVE TH TREA HEALTH NSURANCE POLICY NUMBERS: MEDICARE a- MEDICAID AARP BLUE CROSS 6146,30 BLUE SHIELD? PACE OTHER LONG TERM CARE NSURANCE FINANCIAL STATUS: Qp(J SOCIAL SECURITY 5 PENSION S 7J b D. D U AN'v-UITY INCOME S OTHERS- ASSETS: CHECKING ACCOUNZT-BANK Fh1C AMOUNTS IC700' O O _ ??dn. 6D SAVINGS ACCOUN-17-BANK AMOUNT $ CERTIFICATE OF DEPOSIT-BANK AMOUNTS CASH AND/OR OTHER INVESTMENT, ?Siar1L- L,i `L- LIFE INSURANCE-COMPANY ?- FACE VALUE S REAL ESTATE-LOCATION /t nrlS, NAME (S) ON DEED VALUES LIST ANY AND ALL ASSETS THAT HAVE BEEN TRANSFERRED DURING THE PAST 3 YEARS, INCLUDING THE DATES OF TRANSFER DOES THE APPLICANT HA EXECUTOR'S NAME EXECUTOR'S ADDRESS EXECUTOR'S TELEPHONE PREFERRED FUNERAL HO Address Telephone k ARE ARRANGEMENTS PRE-PAID? n D PLEASE INCLUDE COPIES OF APPROPRIATE CARDS (SOCIAL SECURITY, MEDICARE, ETC.). PLEASE ADD ADDITIONAL SHEETS OF PAPER TO EXPLAIN INSURANCE INFORMATION. YOUR PHOTOGRAPH WILL BE USED FOR IDENTIFICATION PURPOSES IN THE MEDICAL RECORD AND ELSEWHERE AS NEEDED FOR PROPER IDENTIFICATION. . CAO ,. aWESTMINSTER DRIVE '..0. BOX 599 :ARLISLE PA 17013-0599 SAO RETURN ADDRESS UNIT pp CSLD 0017 '01010000000' JOANNE K COOPER CLAREMONE NURSING & REHAB 1000 CLAREMONT DRIVE CARLISLE PA 17013 Medicaid for Aged NMP Long Term Care .,.GD&a',,;REGDRD"? 11??u?vg?x„ 21 0095888 PAN 0 IF YOU DO NOT UNDERSTAND OUR DECISION OR HAVE ANY WESTIONS. PLEASE CONTACT YOUR WORKER IMMEDIATELY. WORKER: R VOGELSONG WORKER ID: TELEPHONE: (717) 240-2700 DATE: 09/15/2004 NOT: 042 OPT: 0 TYPE: N requested verifications of bank accounts, money markets & stocks were not received. RECEIVED REGULATIONS: 55 PA Code 201.1 SEP 2 0 2004 CNAQ MEN 8 IRVINE ROW FAIR HEARING LEGAL SERVICES,INC. :ARLISLE PA 17013 APPEAL AND If you disagree with our decision, you have the right to appeal. See attached form for a complete explanation of your right to appeal and to a fair hearin . DETACH HERE DETACH HERE .... _ bliffol r r • Notice ID: 58652488 JOANNE K COOPER -LAREHONE NURSING & REHAB :000 CLAREMONT DRIVE 21 0095868 PAN 0 -ARLISLE PA 17013 CUMBERLAND CAC, 33 WESTMINSTER DRIVE P.O. BOX 599 CARLISLE PA 17013-0599 WORKER: H VOGELSONG APPEAL TELEPHONE (717) 240-2700 DATE 09/15/2004 NOT. 042 OPT: 0 TYPE N NOT ELIGIBLE NOTICE Notice ID: 59652488 PAGE 1 OF 1 ?e Gtia 1000'Claremont Road Carlisle, PA 17013-8805 main (717) 243-2031 fax (717) 240-1952 Peb,abilitation Center September 16, 2004 Ms. Laurie Weller 108 May Dr. Apt #I Camp Hill, Pa. 17011 RE: JOANNE COOPER - OUR RESIDENT ACCOUNT #4406 Dear Ms. Weller: The Claremont Nursing and Rehabilitation Center has received notification from the County Assistance Office that Mrs. Cooper's Medical Assistance application will be denied due to non-receipt of information requested by the Assistance Office. Since Medical Assistance will not be paying for Mrs. Cooper's care, we must assume her care will be paid for by private pay. It is our policy to request a Private Pay Room Deposit of $6,355.00 (31 Days X S205.00/Day) which is to be held and applied to the last month of Private Pay. Also, the private pay room and board bills from January 2004 through August 2004 in the amount of $45,435.00 are now due and owing. Please remit payment to our Business Office at the above address. Should you have any billing questions, please feel free to contact Denise Lehman at (717) 240-1908. Should you have questions regarding the Medical Assistance application, please contact Dian Myers at (717)240-1929. Sincerely, - --. - - ?. Mary Kimmel Finance Manager Enclosure: Medical Assi,_ Private Pay B." NWdl ¦ Complete items 1, 2, and 3. Also complete item 4 it Restricted Delivery is desired. ¦ Print your name and address on the reverse so that we can return the card to you. ¦ Attach this card to the back of the mailpiece, or on the tront H space permits. (?3?1 Uticle Addressed to: I os x--DA 11r. eYa 2. Ar .. . by F,18 M Print CW I a. C. signature t7 Agent X C;*G ? ? Addre D. Is delivery address different Uom Item 11 ? Yes ff YES, enter delivery address below.. ? No as for Merchand se ? C.O D WP' Yes NOTICE TO APPLICANPQ;? I 'II 1-800-2690173 717-240-7700 DEPARTMENT OF PUBLIC WELFARE • 1119 If - • • I - fall' • _ e , e • • - • GUAVSENLANU GUUN I T ASSR IANOE OFFICE 33 WESTMINSTER DRIVE P. O. BOX 599 CA S BENEFIT EUGI9L£ NOT r ELIWBLE EROx+e RLI LE. PA 17013-0599 ? ASSISTANCE CHECK After me Just check when maY? a saecial amoVrlt you win receive S ? Twice a Month ? Once a Month ? In me Ma4 ? Al me Bank MEDICAL SSISTANCE ? You lave a patient pay liability of S for me penott beginning and ending ? Enecove Date ? FOOD STAMPS You will receive 5 Ito, me month(s) of Van you wN receive bad stamps in me amount U S a monm from to ? In out mail ? At Me Bank O'NURSING HOME CARE Level of rare authored you are ••petad m pay S a momb toward your care. [3 SERVICES C] OTHER THE FOLLOWING PERSONS ARE INCLUDED NO NAME .HE" i $TOAMPS I ASST. I SERVICE NO. NAME CHASST. ECK STAMPS I ASSDT. $cR E ctnn 'oo I .r ?8Y I I I i I l,LL' 0, C ors d;L-I 6-e-) ,?I I " ?p ,. ?.? a + Y f 4-t Q ? D?1( a pu AN D\JI?\Sl . 01 QrFOOD STAMPS Number of Personell? Name GROSS MONTHLY EARNED INCOME 11101010111:114;MA? Q ASSISTANCE CHECK - Number of Persons III GROSS MONTHLY Name EARNEDINCOME $ 4//i Is $ $ / S Name GROSS MONTHLY UNEARNED INCOME Name GROSS MONTHLY UNEARNEDINCO E $ / $ / TOTAL GROSS MONTHLY INCOME S TOTAL GROSS MONTHLY INCOME $ GROSS MONTHLY DEPENDENT CARE COSTS S GROSS MONTHLY DEPENDENT CARE COSTS is GROSS MEDICAL COSTS S j Telephone I Water/Sewage Q MEDICAL ASSISTANCE Number of Persons Illi, Electric Gas Garbager7rash Utility Installation I Name GROSS MONTHLY EARNEDINCOME S I/// Oil Other I s V GROSS UTILITY COSTS/UTILITY STANDARD' S /i S RENT/MORTGAGE $ Name INCOM GROSS MONTMLY UNEARNED INCOME TAXES INSURANCE COST ON HOME S TOTAL SHELTER COST $ $ r-i? 'The household may Switch between the actual utility Costs and the TOTAL GROSS MONTHLY INCOME S . standard utility allowance at the time of reapplication and one additional time d i h l NET MONTHLY INCOME/NET SEMI-ANNUAL INCOME is ur ng eac twe ve-month period. INCOME LIMIT Is CO RECORD NUMBER CA- CTR DIG DIST z, GS4 g? ?? r ?? , '{?i? ? `1(x)3 L ??V Date Telephone Number l- •. ar a? ?naLEGAL HELP IS AVAILABLE AT NOV 3 2004 ART FISfAL DT- LEGAL SERVICES, INC. 8 IRVINE ROW I?RLISLE, PA 17013-3019 x243-9400 717-766-8475 It you do not understand our decision or have any questions. contact your worker. ?O ylt xursl? -eb,abilitation Center November 4, 2004 Ms. Laurie Weller 108 May Dr. Apt ;#1 Camp Hill, Pa. 17011 171 art S r-? OFFICIAL =USE a.. 37 c.rmwd Fee C3f Salem Flacierll Fee l Requir" ?S C3 11-0 a.d DawN r.e a cal Rem C3 Total Postage 8 Feet Is M O SaW To or PO Box Na _.LU Ll.. _ - ^' •».?..'^?».-..-.... C7ry, Sale. ZIfYa ??_ Cc-v. RE: JOANNE COOPER - OUR RESIDEN'T' ACCOUNT 14406 Dear Ms. Weller: We had contacted you previously regarding the Private Pay bills due and owing to Claremont for Mrs. Cooper's care. The private pay room and board bills from January 2004 through October 2004 in the amount of $57,940.00 are now due and owing. Failure to pay the required charges for Nursing Home care is a serious matter. It can lead to discharge, collection procedures, and/or legal action. If we have not received payment or acceptable arrangements within the next 10 days, we will be forced to refer this matter to our attorneys for appropriate action. Should you have any questions, please feet free to contact Denise Lehman in our Business Office at(717)2_40-1908. Thank you for your cooperation and assistance in this matter. Sincerely, Mary Ki Finance Manager MK/dl ¦ Complete items 1, 2, and 3. Also complete item 416 Restricted Delivery is desired. ¦ Print your name and address on the reverse so that we can return the card to You- x Attach this card to the hack of the mailpiece, or on the front if space permits. t. Article Addressed to: L,Gvr? W2JLW • Our C. X Delivery 0 Yes D. Is delivery address ditt from'tout 17 No if YES, enter delivery address Abelo?. (Z pk #? 1 a. Service TYPO D Certified mail C ,,,. TT ??,, t 0,3 j` 11 Registered \\ ? Insured Mail S?' S_ 4. Resoictad COliw -xw 2 Amide NumberllCAPY ?"C°?r • { i { t t11 ' • i ' - .,rl s t "7 bo3l?? to-} ?to?tl, l\°tA 1?{??` r i t] Yes 14002900173 717.240•Z70D DEPARTMENT OF?UBUC WELFARE • - : as • a• ar • • • C as : a - a' a• • • • • I ttArapcr.av.Y ?w . 4C Vn?a.'t 33 WESiM:&F R ORNE P. O. 578 CARLISLE PA 17013,0599 BENEFIT 9.'meLE E?aIeLF r erroa?6 . ASSISTANCE CHECK Ma V'• frst d'arA wY'tn may be a so.aal amour. You wel raowve s ? Twin a Alor'm ? Orce a Monet ? !n e» Atatl ? M " back MEDICAL ? ASSISTANCE ? You haves • weed WY seoiilY of s br m• Pe b.9w"V a'a er'ti n7 ? ENecevs OaM ?FOOO STAMPS Y. wa nave s W 0'a npr'o'IS) d srn Yoe wk r•uiw rooe carps h.a amount d 5 a monm han to ? In ero Mail ? At e'. Bark NURSING HOME CARE Laval d nn aumpiira You are •xpoc W m oay S a monm mwua you nro. RVI"CES ? ' N THE FOLLOWING PERSONS ARE INCLUDED. - - -, _ - _ .. - fOiNOE NAME CHECK ASPOOK) STSTAMPS i MASSED., I SERVICE NO. NAME &T STAMPS I $$T. SEa CC o I _ I I I • as la • • ' • R uwo ` Reason CO ?f fir' /?/y///nnD li vn ,S •• ? ? ?ar.?x?t..?? ?.Yc rr - G ?(_ c ?/-o/u! .' //may ??!'US(i r11s. ?r?i?Ar •I KS?(°a? ?.SS•^? G.•.. rG J('Y Tr"?r 3 /i•..? /{ y Vu,F• o•F ?t.?'?- or.??or G1110;?- Sate. I•F• Se ,¢cr„?s,? ?',.J 6<u...?e.. c? r IO ?a..f- of .2604? 4,W00 144.•e- THE FOLLOWING ITEMS WERE-TAKEN INTO CONSIDERA -[7: FOOD STAMPS- --- ._ ".-. NtantierU Persorm? TION IN DETERMINING THE AMOUNT OF YOUR 13ENEFRS L.0 ASSISTANCE CHECK7R.4 ?. .?•: 'Ntintier-oP Per:ans? Name GAINED NTH Y INCOME Name GROSS MONTHLY EARNEDINCOME s S i $ S 7777777 Is Is Name I GROSg MONTHLY UNEARNED INCOME Name __GROSS MONTHLY UNEARN D INCOME $ s $ TOTAL GROSS MONTHLY INCOME Is TOTAL GROSS MONTHLY INCOME - g ' GROSS MONTHLY DEPENDENT CARE COSTS i s GROSS MONTHLY DEPENDENT CARE COSTS J s GROSS MEDICAL COSTS S Telephone I water/Sewage MEDICAL ASSISTANCE Number of Persons?j Elettric GarbagalTrasn Name GROSS MONTHLY EARNED INCOME Gas Utility Installation IS ////// Ou Other I Is v////// GROSS UTILITY COSTS/UTILrrY STANDARD' s I S ////// RENT/MORTGAGE Name GROSS MO UNEARNED I NTHLY NCOME TAXES g // INSURANCE COST ON HOME is K141111, Is ////// TOTAL SHELTER COST 5 g ///// ?-rhe-houSehold.May Switch between -Me.-a YUal-vUlity.. cc= and Me TOTAL GROSS MONTHLY INCOME Is Standard Uldny attowerce at the 8me Of reapprlcebon and one • addition l ti NET MONTHLY INCOMEINETSEMI-ANNUAL INCOME I's a me during each twelve-monvi pehod. INCOME LIMIT Is CO RECORD NUMBER CAT CTR DIG D15T Jo-t 21 9 ?.g? r ? GGe.-o RE, Orty ..•L? : 11tun? aJ?ilur 64- ?CepY. FISCAL d YO i-dO riot twldemorM our decision r hawarry quesfions• ro faa your worker. Zyo-a-7o Tahpnone Number L HELP IS AVAILABLE AT 2 1 2004 LEG8 ITMNE ROW INC. PA 17 PARTM 7668475 7 E? RC "' 16t ?V ur X 0 4 ? r 07 G ? A C4dMW Fse a rehabilitation Center January 3, 2005 Ms. Laurie Weller 108 May Dr. Apt "I Camp Hill, Pa. 17011 ? Realm RedeptFM o (E?mlaawne RePlxed) D R C3 RaRUlndl Eneo :. I O m 0 C3 r- RE: JOANNE COOPER - OUR RESIDENT ACCOUNT 4406 Dear Ms. Weller: 1000_(7aremont: Road arlrsleq PA 17013-8805 main (717) 243-2031 fax (717) 240-1952 The Claremont Nursing and Rehabilitation Center has received notification from the County Assistance Office that ivlrs. Cooper's Medical Assistance application was denied due to non-receipt of information requested by the Assistance Office. Since Medical Assistance will not be paying for Mrs. Cooper's care, we must assume her care will be paid for by private pay. The private pay room and board bills from January 2004 through December 2004 in the amount of 569,010.00 are now due and owing. Please remit payment to our Business Office at the above address. Failure to pay the required charges for Nursing Home care is a serious matter. It can lead to collection procedures and/or legal action. If we have not received payment or acceptable arrangements within the next 10 days, we will be forced to refer this matter to our attorneys for appropriate action. Should you have any billing questions, please feel free to contact Denise Lehman at (717) 240-1908. Should you have questions regarding the Medical Assistance application, please contact Dian Myers ""`^"^ ' ^1^ Sincerely, Mary Kimmel Finance Manager ¦ Complete items 1, 2, and 3. Also complete A, item 4 if Restricted Delivery is desired. ? C ¦ Print your name and address on the reverse so that we can return the card to you. ¦ Attach this card to the back of the mailpiece, or on the front if space permits. Article Addressed to: Enclosure: Medical Assista: Private Pay Bill: MK/dl > (? 1-711 by (Please Print Clearly) B. Date of Delivery Agent is delivery ad If YES, enter No 3. Service Type Certified Mail 0 Express Mail ? Registered V Retum Receipt for Merchandise ? Insured Mail 0 C.O.D. 4. Restricted Delivery? (Extra Fee) 0 Yes 2. Article Number (Copy from service label) Xser -70c,3 \O\O Oo0\ \\qo\ \`\06 PS Form 3811, July 1999 Domestic Return Receipt 102595-00-M-0957 01/12/2005 Resident Open A/R File [PA614] Page 1 4406 Joanne K Cooper G/L Due Fin Type Notes Fac State Bill date - From Cl Level Chg. Balance ----- ---- 1 ----- PA --------- 01/31/2004 ---- PP ---- PP ----- SNF ---- - RB ------- 1,850 --- .00 1 PA 02/28/2004 PP PP SNF RB 5,865 .00 1 PA 03/31/2004 PP PP SNF RB 6,355 .00 1 PA 04/30/2004 PP PP SNF RB 6,150. 00 1 PA 05/31/2004 PP PP SNF RB 6,355. 00 1 PA 06/30/2004 PP PP SNF RB 6,150. 00 1 PA 07/31/2004 PP PP SNF RB 6,355. 00 1 PA 08/31/2004 PP PP SNF RB 6,355. 00 1 PA 09/30/2004 PP PP SNF RB 6,150. 00 1 PA 10/31/2004 PP PP SNF RB 6,355. 00 1 PA 11/30/2004 PP PP SNF RB 6,150. 00 1 PA 12/31/2004 PP PP SNF RB 4,920. 00 Claremont Nursing & Rehab 2 3 PATIENT CONTRA N0. 1000 Claremont Drive 4 406 Carlisle PA 17013 5 FED. TA%N0. 6 STATEMENT COVERS PERIOD REM TWO 7 COy D. B N-C D. 9 GI 0. 10 4 0. 11 717 243-2031 23-6003119 012204 013104 010 PATIENT NAME Cooper, Joanne K 15 PATIENT ADDRESS - SIP.TNDATE 155'_1 16 MS n wrz ADMISSION NH 1e 7yPE y? 21 D HR 22 STAT M MEDICAL RECORD NO. s. Pa _ 31 06021928 F 012204 30 4406 +oE OCCURRENCE E '{ 34 OCCURRENCE COw wNE 36 CODE OCCURRENCE SPAN FRCA TIRDUGX 37 3 B 39 CODE VALUE CODES AYN 41 CODE VALUE CODES AMpMf Joanne K Cooper Laurie Weller i08 May Drive #1 r I . PA 17011 a b D d REV. CC 43 DESCRIPTION N HCPCS IRATES 45 SERV. DATE 16 SERV. UNITS 47 TOTAL CHARGES 46 NON-COVERED CHARGES 49 0120 0001 I I I i R & B NURSING CARE - SE TOTAL CHARGES 185.00 10 1850.00 10 1850i00 I I PAYER 51 PROVIDER N0. 54 PRIOR PAYMENTS 55 EST. AMOUNT OJE M PRIVATE PAY CLAREMONT ? •o INSURED 'S I:AME S9PREL WCERT. SSN-HIC. ID NO. 61 GROUP NAME 621NSURANCE GROUP NO. Cooper Joanne K 01 159228760 AUTHORIZATION CODES 6+ESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION j _'HINDIAG C N C E 7176 ADMDIAL. OD. r E-CODE 73 25000 25000 PRINCIPAL PROCEDUII R DURE 92 ATTENDING PHYS.b Coo' D. ., caoE wTe OTHER PROCEDURES ? ...: OTHER P? CODE =RE wTE C27772 HARM MD KENNETH R M OTHER PHYS. ID 1tMFHKb OTHER PHYS. ID 01/11/2005 . Repy Wd Paper Claremont Nursing & Reha 2 3PATIENTCOMROLND 1000 Claremont Drive 4406 Carlisle PA 17013 5 FED. TAX NO. 6 STATEMENT COVERS PERIOD EROU THRpIGH ] COV D. 6 NC D. 9 GD . 10 D. 11 717 243-2031 23-600311 020104 022904 029 PATIENT NAME Coo er Joanne K 13 PATIENT ADDRESS BIRTHRATE 155E% 16 MS n RATE AaA1Id ? 1B p y? 21 O HR 22 STAT 23 MEDICAL RECORD N0. N M se ?p 31 0602192 F 01220 3 4406 OCCURRENCE ??? DATE _ % OCCURRENCE caRE w,TE 36 mDE OCCURRENCE SPAN RiOM THRg19x A B ' 39 VALUE CODES LORE AM' yt - 3. •, Al CODE VALUE CODES ugLM Joanne K Cooper Laurie Weller 108 May Drive #1 Cam Hill PA 17011 a b c d 'c+ CD. 43 DESCRIPTION AC HCPCS/RATES 45 SERV. DATE a6 SERV. UNITS n TOTAL CHARGES %6 NON-COVERED CHARGES e9 012q R & B NURSING CARE - SE 0120 R & B NURSING CARE - SE 0007 TOTAL CHARGES I II I I I 185.00 205.0 2 2 740;00 5125. 5865;00 PAYER 51 PROVIDER NO. 51 PRIOR PAYMENTS 55 EST. AMOUNT DUE 55 PRIVATE PAY CLAREMONT INSUREDS NWE 59 PAR 6D DEPT .SSN HI C. ID NO. 61 GR06P NAME 62 INSURANCE GROUP NO. Cooper Joanne K 0 159228760 TREATMENT AI HORIZATION CODES ME5C 65 EMPLOYER NAME 66 EMPLOYER LOCATION PRIN. DIAG. CC. CODES r, cOOE _ croE -"x- mmoE S 76 ADM. DWG. CO. P ECOOE ]B 496 25000 2500 `.C. CO PRINCIPAL P CDDE ROCEDURE 1 THER DATE DAh DD6E 82 pTTENdNG PHYS. ID C27772 HARM, MD K N OTHER PROCEDURE TARE D<TE wDE wTE 63 OTHER PLAYS. 10 ?LMANKS OTHER PHYS. ID 01/11/2005 Claremont Nursing & Reha 2 3 PATIENT CONTROL NO. 1000 Claremont Drive 4406 Carlisle PA 17013 5 FED. TAX NC. 6STATEMENT COVERS PERIODy DDV O. 8N-0D SGIO 16L-PD n 2031 7 7 113 23-60631191 03010 4033104 - 031 PAtIENT NAME I 13 PATIENT ADDRESS EIRTHDATE 155'_X 15 MS n DATE R N nP? p BRC 3I D HR 22 ETAT 23 MEDICAL RECORD N0. zr W-M CON x 31 0A0219281 F1 0 204 30 4406 OCCURRENCE ,>pE Wif S' ^.s :. . 36 OCCURENCE CODE DATE 36 flAE. OCCURRENCE SPAN FRdI TIRUIII`H 337 0 36 CODE VALUE CODES AY3UNf 41 DDDE VALUE ODDS AMWHT Joanne K Cooper Laurie Weller 108 May Drive #1 Camp Hill. A 17011 a t C d RE, CD. 43 DESCRIPTION N HCPCS: RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTAL CHARGES 48 NON-COVERED CHARGES 49 01201 R & B NURSING CARE - SE 00011 TOTAL CHARGES I i I I i I 205.00 I 31 31 I I 6355.00 635500 IAY'ER H PROVIDER NO 56 PRIOR PAYMENTS SS EST. AMOUNT DUE 56 PRIVATE PAY CLAREMONT ? •e ?.NSURED S NAME YP REl 60 CERT SSN - HIC. ID NO. EI GROUP NAME U INSURANCE GROUP NO. -ooper Joanne K 01 155228760 EN7 AU7HO111,R DN CODES NESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION ; C D . T6 ADMDIALCD. r ECODE ]8 2943 PRINCIPAL PROCEWI'= WoE R DU ?h i.0:A D, NNW oPE 25000 g2 ATTENDING PHYS. ID OTHER PROCEDURE ? C27772 HARM, MD KENNETH R RODE DtIE ; ? mpE MiE 83 OTHER PHYS. ID I OTHER PHYS. ID 01/11/2005 Claremont Nursing & Reha 2 3 PATIENT CONTROL NO. 1000 Claremont Drive 4406 C a r l i s l e PA 1 7 0 1 3 5 FED. TAX NO. 6 STATI.WNT COVERS PE, A„ 7 GOV D. B N-C D. 9 cI J. 10 L-R D. 11 717 243-2031 23-600311 04010 04300 03 PATIENT NAME Cooper, Joanne K 13 PATIENT ADDRESS = DIRTHDATE IS SEX 16 MS 17 OArt ADMIis w SSION 1s TwE m W 21 D HR 22 $TAT 23 MEDICAL RECORD NO. a ICON O DES p 31 0602192 F 01220 3 4406 OCCURRENCE :xE DATE - 34 OCCURRENCE cw6 DATE 36 mDE OCCURRENCE SPAN RPM 711p 11 3] A I B 39 VPllIE CODES CWE AMD{INf 41 (A,p[ VALUE CODES AyDlryl Joanne K Cooper Laurie Weller 108 May Drive #1 Cam Hill PA 17011 a b c d REV. CO. 43 DESCRIPTION 44 HCPCS/RATES 45 SERV. DATE 46 SERV. UNITS 47 TOTk CHARGES 4 NON-COVERED CHARGES 49 0120 000 I I R & H NURSING CARE - SE 1 TOTAL CHARGES I ? I 205.0 I 3Q 312 6150;00 6150;00 "A?EF 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 PRIVATE PAY CLAREMONT T '4SJREC'SI M5 59 PAEL 60 CEP' SSN RIC.- ID NO. 61 GROUP 14AME 62 INSURANCE GROUP NO. Cooper Joanne K 0 159228760 : REATMEf,' A'sHORIZATION CODES AE6C 65 EMPLOYER NAME 66 EMPLOYER LOCATION PRIN. DIAG. CD. NDF „..Y? ID GCOE G. CODES 11111111111110 - >sNOE 496 2988 C W PRINCIPAL PROCEDURE 1 TM EIXAi Coo[ DATr W1E 74 WDF 'Z-.. 76 ADM. DIAG. CD. n E-CODE 78 25000 @ATTENDING PNYS ID -1 OTHER PROCEDURE .. ..:., ..- 1 1 C27772 HARM, MD KENNETFF-R-- DATE caoE p,,h B3 OTHER S. ID OTHER PHYS. ID 01/11/2005 Claremont Nursing & Reha 2 3 PATIENT CONTROL NO 1000 Claremont Drive 4406 Carlisle PA 17013 5 FED. TAX NO. 6SAMCOVERSP COV D. BNCD 9C-ID 10L-RD 11 717 243-2031 23-6003119 050104 053104 031 PATIENT NAME Cooper, Joanne K 13 PATIENT ADDRESS = RIRTHDATE 15 SEX 16 MS 11 DAR ADMISS'IION 1E ivPE p SP.O 21 D HR 22 STAT 23 MEDICAL RECORD N0. S 90 31 06021928 F 012204 6 30 4406 OCCURRENCE 34 OCGJflRENCE :ODE WTE LODE MTE 0 .e+ - 3fi CODE OCCURRENCE SPAN Rid4 TNNd3IiH 37 A B 39DDaE VAWECOA1101DF57 ?, 411 VALUE CODES Joanne K Cooper Laurie Weller 108 May Drive #1 Cam Hill PA 17011 a b c d 2 REV. CD. 43 DESCRIPTION U HCPCSI RATES 45 SERV. DATE /6 SERV. UNRS 47 TOTAL CHARGES 46 NON COVERED CHARGES 49 0120'R & B NURSING CARE - SE 0001i ; TOTAL CHARGES I I i ' 205.00' I I 31 31 6355;00 6355.00 PAYER 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 PRIVATE PAY CLAREMONT INSUREDS NAME 59P EL W DEPT .-SSN HIC.-ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. Cooper Joanne K 01 159228760 ETMEr;i AlflHOR"ATION CODES A nIEY fi5 EMPLOYER NAME fib EMPLOYER LOCATION ; N. DIAG. CD. CODES N OODE 70 ? ?... ire taDE 74 DODF 76 ADM. DUG. CD. 77 E-CODE 76 19 6 1988 25000 80 CODE1NCIPAL PigCEDUDI= I THE DATE ATTENDINGPHYS.ID C27772 HARM MD KENNETH R OTHER PROCEDURE DATE OTHER CDOE LOOS DATE 83 OTHER PKI-S. ID REMARKS OTHER PHYS.W 01/11/2005 PnnIW on Recyc ed Paper Claremont Nursing & 2 - Reha J YA,IGNI GVnInVl lrv . 4406 1000 Claremont Drive 6 STA?EM COVERS PERIOD 7COY0 eN-CD 901 D. ,0 4RD 11 Carlisle PA 17013 5 FED. TAX NO. 06010 * 06300 03 717 243-2031 23-600311 13 PATIENT ADDRESS PSTIEM NAM" Coo er Joanne K CON ODES 31 DIRTHDATE ,SSEX 16MS AdA551IX1 21 D HR 22 STAT 23 MEDICAL RECORD NO. it GATE ism N IYfE P W 9. zE 77 x x 0602192 F 01220 3 4406 36 37 RENCE SPAN RRENCE OCCU 34 OCCURRENCE 4 pA CSpE „ A FROM p D E B 39 VALUE O S Al VALUE CODES A401Mf Joanne K Cooper a Laurie Weller b 108 May Drive #1 C Cam Hill PA 17011 d a HCPCS;RATES 45 SERV. DATE 9 SERV. UNITS O TOTAL CHARGES m NON COVERED CHARGES 49 ;EV. CD. e3 DESCRIPTION 0 RE - SE 205 3 6150100 012 R & B 14URSING . 1 CA 3 6150.00 0001 TOTAL CHARGES 1 1 I I I 'AY'cR 51 PROVIDER NO. 5A PRIOR PAYMENTS 55 EST. AMOUA?DUE 56 PRIVATE PAY CLAREMONT INSUREDS NAME 59 PAEL 60 CERT.. SSN HIC. - ID NO. 61 GROUP NAME 621k$URANCE GROUP NO. -ooper Joanne K 15922876 j TREATMENT AUTHORIZATION CODES MESC 65 EMPLOYER NAME 66 EMPLOYER LOCATION ]6 ADM. DIAL. CD. r ECODE 76 ?RIN. DIAL. GD. N C00? N WDE R E .q... a 496 2988 -- 60 o INCIPAL PROCEDURE 8 j 1 OTHER PROCEDURE - V An 62 ATTENDING PHYS.W D? E c woO OTHEP, :;t ,':. CaoE diE LC1 OTHER PLAYS. ID DAtE nEMARKS OTHER PHYS. ID 01/11/2005 Claremont Nursing & Reha 1000 Claremont Drive 2 3 PATIENT CONTROL NO 4406 Carlisle PA 17013 ED. TAX NO. 8 STATEMEMCOVERS PEWOD TI« H 5 F FROM - 7 CDV D. a N-0 D. 9 UD. 1D l-fl D. n 717 243-2031 23-6003119 070104 073104 031 PATIENT NAME Cooper, Joanne K 13 PATIENT ADDRESS - BIRTHDATE 15 SEX 16 MS 17 DATE ?g HIR N TYPE p W 21 0 HR 22 $TAT 23 MEDICAL RECORD N0. ,y x p 31 0602192811 F 012204 30 4406 OCCURRENCE uo6 DATE .?a.« 34 OCCURRENCE co 94 E 3fi roof OCCURRENCE SPAN Fp TNW]IIA4 37 A I J B 39 woe VALUE CODES AYp14f 41 rooe VALUE CODES MIO1Mi Joanne K Cooper Laurie Weller 108 May Drive ,41 Cam Hill PA 17011 s b C d . REV. CD. 43 DESCRIPTION 44 HCPCSIRATES 45 SERV. DATE 4 SERV. UNITS 47 TOTAL CHARGES 46 NON-COVERED CHARGES 69 01201 R & B NURSING CARE - SE 00011 TOTAL CHARGES I i I i i, I i i I I 205.00 31 31 6355:00 6355;00 PATER 51 PROVIDER NO 54 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 PRIVATE PAY CLAREMONT :NSJRED'S NAME 59P RE1 W CERT. SSN. HIC.- ID NO. 61 GROUP NAME 62 INSURANCE GROUP NO. ooper Joanne K 01 159228760 iREATMEl NaTION CODES AaTHO ME9D 65 EMPLOYER NAME 66 EMPLOYER LOCATION ; PRIN. DIAG wOE p woi 496 400 ' .C N ALPROCEDUI o:. wre NDING PNYS.ID OTHER PROCEDURE ro1x - wo[ w.e oA1T C27772 HARM MD KENNETH R B3 OTHER PH ID ,EMARNS ' OTHER PHYS. S) 01/11/2005 Claremont Nursing & Re ha 2 3 PATIENT CONTROL NO 1000 Claremont Drive 4406 Carlisle PA 17013 5 FED. TAx 0. 6STAT COVERS ICOV D. 8N-CD 9CID. 10 LAD 11 717 243-2031 23-600311 08010 083104 031 PATIENT NAME Coo er Joanne K 13 PATIENT ADDRESS SIRTHDATE 15 SEX I6MS 17 DAN ADMISSION to p 21 D HA 1 22 STAT 23 MEDICAL RECORD NO. N M m n 71 0602192 F Y 01220 3 4406 RENCE WE OCCURwTE 9A OCCURRENCE CODE wTE w CODE OCCURRENCE SPAN NIW THROWN 37 A B 39 GOOE VALUE CODES AYOU1f 41 C/'OE VALUE CODES AMDLNf Joanne K Cooper Laurie Weller 108 May Drive #1 Cam Hill PA 17011 a b C d FEV.CD. 43 DESCRIPTION ba HCPCS IRATES 45 SERV.DATE 46 SERV. UNITS 47 TOTAL CHARGES 0 NONCOVERED CHARGES 49 0120 00011 I I i I I R & B NURSING CARE - SE TOTAL CHARGES 205.0 I I I I 31 31 6355:00 6355;00 PAYER 51 PROVIDER N0. E4 PRIOR PAYMENTS 55 EST. AMOUNT DUE w PRIVATE PAY CLAREMONT I :a'SUREOS NAME - 53PREL 60 DEPT-SSN HIC. ONO. 61 GROUP NAME 62 INSURANCE GROUP NO. Cooper Joanne K 0 159228760 TREATMENT AUTHORIZATION CODES MESC 65 EMPLOYE; NAME 6E EMPLOYER LOCATION PRIN. DIAG 00. N WoE >a COOE B E ,? 7? WoE 76 ADM. DIAG. CD. n DE ELD 76 496 72400 2b000 C REMARKS 82 ATTENDING PHYS. ID 93 OTHER PHYS.10 OTHER PHYS ID 01/11/2005 Claremont Nursing & Rehab 2 3 PATIENT CONTROL No. 1000 Claremont Drive 4406 Carlisle PA 17013 * 5 FED.TA%NO. 6SUT?r COVERS PERIOD ! COVD ' 6NCD 9C-ID tOl-R D. 11 717 243-2031 23-6003119 090104 093004 V30 PATIENTNAME 13 PATIENTADDRESS Coo er Joanne K SIRTHDFTE t55EX t6M5 I, DATE Ap IS 21DHR 22STAT 23 MEOICALRECORD NO. m 31 14 p N M so 06021928 F 012204 301 4406 OCCURRENCE - 34 OCCURRENCE 36 OCCURRENCE SPAN 3T ,TIDE DATE CODE DATE CODE FliD1A 11fn2SnI (4 B 39 VALUE CODES I1 VALUE CODES MIOUNf CDOE AMdM Joanne K Cooper a Laurie Weller b 108 May Drive nl C Ca Hi 1 PA 17011 d t REV. CD. 43 DESCRIPTION 44 HOPCSIRATES 45 SERV. DATE 9 SERV UNITS 47 TOTAL CHARGES Q NOWCOVERED CHARGES 49 0121 R & B NURSING CARE - SE 205.00 30 6150:00 0001 I I I I I I i I TOTAL CHARGES 30 615000 PAYER 51 PROVIDER NO. 5,1 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 PRIVATE PAY CLAREMONT INSURED 'S NAME 59PAEl 60 CERT. SSN HIC-IDNO. 61 GROUP NAME 62 INSURANCE GROUP NO. Cooper Joanne K 01 159228760 TREATMENT AUTHORIZATION CODES K'.SC 65 EMPLOYER NAME fib EMPLOYER LOCATION PRIN DIAG CD. 0000 76 ADM CODE - :. •• •. ra CDD6 .... DEpE ;?:.. T? CODE _ ..... . DIAG. CD. ]1 ELDDE )6 496 3499 25000 0 60 PP.", PROCEDUt" 181 OTHER ., COD, D. &2 ATTENDING PNYS.ID DA TE C27772 HARM, MD KENNETH R ER PROCEWR mo ?? woE 7, 63 OTHER PHYS. ID OTHER PHYS. ID 01/11/2005 C 1 aremgnt Nursing & Reha 2 3 PATIENT CONTROL NO. 4406 1000 Claremont Drive Carlisle PA 17013 O. ANCO 9GIO W4R 0. 11 5 FED. TAX NO, is ST^ 'IR;01 CO, ? (717 243-2031 0310 031 191 10010 1 PATIENTNAME 13 PATIENT ADDRESS Coo er Joanne K RIRTHDATE 15 SEX ISMS I] DATE 0MI5S1 19 Type M 6HO 21 D HR 22 STAT 23 MEDICAL RECORD N0. zr x x 31 0602192 F 01220 3 4406 OCCURRENCE 3/ OLCIIRRENCE ••1'- 36 OCCURRENCE SPAN 3] DATE DoE mw nwouTR A DATE B ? VALUE SS 'log 4 VAUIE COM M CaDE Joanne K Cooper a Laurie Weller b 108 May Drive #1 C j Cam Hill PA 17011 d REV. CD. 43 DESCRIPTION IA HOPCSIRATES 45 SERY. DATE 9 SERV. UNITS 47 TOTALCHARGES 4 NON COVERED CHARGES 49 012 R & B NURSING CARE - SE 205.012 31 6355:00 0001 TOTAL CHARGES 1 I 31 6355.00 PAYER 51 PROVIDER NO. 56 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 PRIVATE PAP CLAREMONT NSJREOS NAME 59 PREL W CERT. SSN HID.-ID NO. 61 GROUP NAME 62 INS URANCE GROUP NO. Cooper Jcanne K 0 159228760 TREATMENT AUTHORIZATION CODES RESC 65 EMPLOYER NAME 66 EMPLOYERLOCATION PRIN. NAG CO. .CODES a __,., ADM. DIAG. CO. n E=E 78 76 496 349 2 5 OTHER '.C_ 8V A L P PROCEDURETE cane DA woe PROrE DU + 82 ATTENDING PNYS ID DAT6 ARM, ?OTHEP. PR7RNE moE w1E 83 OTHER PINS. ID REMARKS OTHER PHYS. ID 85 ?MHJKE??IAII?t 06 DATE X 01/11/2005 Claremont Nursing & Reha 2 3 PATIENT CONTROL NO 1000 Claremont Drive 4406 Carlisle PA 17013 5 FED. TAX 6ShENT WVEfl$nMgPERIOD 6n COV D. 6NC D. 9GI D. 10L D. 11 717 243-2031 23-6003119 110104 113004 030 PATIEIRNAME 13 PATIENT ADDRESS Coo er J anne K E&RTHUATE 155E% 16 MS 1T MTE ADMi6 HR 19 TV SRO 2T DHR 22 STAT 23 MEDICAL RECORD NO. yH m 90 31 219281 F1 W 012204 3 4406 OCCURRENCE 3A OCCURRENCE '••:..,., 36 OCCURRENCE SPAN fJJOE FROM THIpIX1H 37 A :JOE MTE MTE B 39 VALUE CODES 411 VALUE OODES AM W Joanne K Cooper a Laurie Weller b 108 May Drive #1 C PA 17011 d - REV. CD. 43 DESCRIPTION c< HCPCS/RATES 45 SERV. DATE 16 SERV. UNITS 47 TOTAL CHARGES 4 NON-GOVEREDCHARGES 49 0120 R & B NURSING CARE - SE 205.00 30 6150.00 00011 TOTAL CHARGES i I I I 30 6150;00 i PAVER 51 PROVIDER NO. 5,1 PRIOR PAYMENTS 55 EST. AMOUNT DUE 56 PRIVATE PAY CLAREMONT INSUREO'SNAME 59PAEl WCERT.-SSN-HIO-101,10 61 GROUP NAME 62 INSURANCE GROUP NO. 7,ooper Joanne K 01 159228760 1 TREATMENT AUTHORIZATION CODES NESL 65 EMPLOYER NAME 66 EMPLOYER LOCATION PRIN. DIAG. CD. M WOE m CLce G. WOES w CODE 76 ADM. DIAG. CD. E{ODE 70 496 3499 25000 - W PRINCIPAL PROCEUUIT QTMER CO?F 0... a >:. lPxa'"' ? MTE 33 ATTENDING PHYG.ID 9 C27772 HARM, MD KENNETH R OTHER PROCEDURE MHkXXUUHt COOF MTE CODE MTE owl I 63 OTHER PRY&ID 1 1 REMARKS OTHER PHYS. ID 01/11/2005 claremQnt Nursing & Reha 2 3 PATIENT CONTROL NO. 1000 Claremont Drive 4406 Carlisle PA 17013 5 FED TAX NO. 6SGEM COVERS PETIR ODD GOVD 8N-C D. 9C-10 10L-R D. 11 717 243-2031 23-600311 12010 12230 02 ?ATIENT NAME Coo er Joanne K 13 PATIENT ADDRESS BIRTHRATE 15 SE% 16 MS n ?? ADMISSION a n I N? 21 D HR 22 STAT 23 MEDICAL RECORD N0. a 31 0602192 F 01220 0 4406 OCCURRENCE ]DE LNTE M OCCURRENCE TMTE - _., 36 CDOE OCCURRENCE SPAN RDE1 TxR3113X 37 A B 39 100E VALE CODES AMC(Mf ' :MME' 41 V.'OE VALUE CODES AIIDIAIf Joanne K Cooper Laurie Weller 108 May Drive #1 Cam Hill PA 17011 a b c d REV. CD. 43 DESCRIPTION a4 HCPCSI RATES 45 SERV.DATE 46 SERV. UNITS 47 TOTAL CHARGES Q NONCOVEREDCHARGES 49 012P? 300 R & B NURSING CARE - SE 1 TOTAL CHARGES 205.0 I 2 24 4920;00 4920:00 PAYER 51 PROVIDER NO. 54 PRIOR PAYMENTS 55 EST. AMOUM DUE 56 PRIVATE PAY CLARERiONT -• 72 INSUREDS NAME 59 P.REL 60 CERT. SSN - HIC. ID N0. 61 GROUP NAME 62 INSURANCE GROUP NO. Cooper Joanne K 0 159228760 r REAE ALTIHORIZATION CODES NESC aEMPLOYER NAME 66 EMPLOYER LOCATION ; G ORCOTElADE )8 3499 25 PRINCIPAL PROCEDURE OURE R ATTENDNG PHYS. 10 CpDE DATE CpDE DATE C27772 HARM, ML) KENNETH-TF- R PROCEOUR NoE ?h CODE DATE 63 OTlEA PHYS. D REMARKb OTHER PHYS.D 01/11/2005 ,y ? ? _ "?' ? ? ?? 1y ? ? ?? r; , -? ? , , r„ ? r ?i a ? .? „? C ?+ ^ W i ? ti t? Michael S. Travis ID No. 77399 Attorney for Defendant 3904 Trindle Road Camp Hill, PA 17011 717-731-9502 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, 1000 Claremont Road Carlisle, PA 17013 Plaintiff V. Laurie C. Weller, 108 May Drive, Apt. #1 Camp Hill, PA 17011 Defendant No. 05-4126 Civil Term Civil Action Law ANSWER TO COMPLAINT AND NEW MATTER NOW COMES, the Defendant, Laurie C. Weller, by and through her attorney, Michael S. Travis, and answers the Complaint as follows: 1-3. Admitted on information and belief. 4. Admitted in part, Denied in part. Admitted that Defendant held the Power of Attorney for her late mother. The implication that Defendant agreed to pay the debt by the Power of Attorney is denied. 5. Admitted on information and belief. 6. The characterization of Exhibit "B" is denied. The Exhibit speaks for itself. 7. Admitted in part, Denied in part. It is admitted that Defendant signed the Agreement. The implication beyond definition in the Agreement is Denied. 8. Denied. The terms of the Agreement speak for themselves. 9. Denied. The characterization of her duties are outlined in the Agreement. By way of further answer, Defendant did perform according to her obligations as the "Responsible Party.,, 10. It is Denied that Defendant failed to use Joanne Cooper's assets to pay the nursing home as provided in the Agreement. Strict proof of failure to do so is demanded at trial. 11. It is specifically Denied that Defendant used Joanne Cooper's assets or resources for herself and or others. By way of further answer, Defendant paid her mother's required obligations leaving no assets for payment to Plaintiff. 12. Admitted in part, Denied in part. It is Denied that Joanne Cooper received monthly Social Security benefits. It is admitted that Joanne Cooper received an $880 monthly pension. The contents of Exhibit C are Denied. The Exhibit speaks for itself. By way of further answer, of the $880 received, after her mother's auto insurance, meals, pocket money and clothing were paid there were few if any benefits remaining. 13. Admitted in part, Denied in part. It is specifically Denied that Defendant's mother received a Social Security check. It is Admitted that her mother received a pension check. 14. It is Denied that Defendant failed to make Medical Assistance application or respond to the requests of the Plaintiff. By way of further answer, Defendant took paperwork to both the PNC Bank, and Commerce Bank at least three times. They returned the paperwork asking for supplemental information. Joanne Cooper died before the Medical Assistance application could be completed. 15. Admitted. 16. Denied that Defendant failed to pay Plaintiff or that she was obligated to do so. It is Denied that $69,010 is owed by Defendant. The contents of Exhibit "B" are denied, the contents speak for itself. ANSWER TO COUNT I - BREACH OF CONTRACT 17. Defendant incorporates the contents of Paragraphs 1 - 16 of her answer as though set forth at length herein. 18 - 19. Admitted. 20. Denied. Defendant is unaware of payments Plaintiff may have received, the averment of Paragraph 20 is Denied. 21. Denied. Defendant is unaware of payments Plaintiff may have received, the averment of Paragraph 21 is Denied. 22. Denied. It is Denied that Defendant failed to keep her mother's account current or that she failed to assist in the preparation, completion, and submission of a Medical Assistance application as a breach of contract. WHEREFORE, Defendant prays this Honorable Court to dismiss the Complaint of Plaintiff, and award her counsel fees and costs for defense of this Complaint. ANSWER TO COUNT II - QUANTUM MERUIT 23. Defendant incorporates the contents of Paragraphs I - 21 of her answer as though set forth at length herein. 24. Admitted. 25. Denied. It is Denied that Defendant received her mother's assets and / or income and field to pay for services to Plaintiff. It is Denied that she has been enriched in any way. 26. Admitted in part, Denied in part. It is admitted that Plaintiff should receive payment for reasonable services provided to Joanne Cooper, available from medical assistance and her estate, but not from the Defendant. WHEREFORE, Defendant prays this Honorable Court to dismiss the Complaint of Plaintiff, and award her counsel fees and costs for defense of this Complaint. ANSWER TO COUNT III - BREACH OF FIDUCIARY DUTY 27. Defendant incorporates the contents of Paragraphs 1 - 26 of her answer as though set forth at length herein. 28. Admitted in part, Denied in part. Admitted that Defendant was the Power of Attorney for her mother. Denied the implication that in holding her Power of Attorney she agreed to pay her mother's nursing home bill. It is also Denied the implication that she failed to tend to her duties as a Power of Attorney. 29. Admitted in part, Denied in part. Admitted that Defendant acted as her mother's Power of Attorney. It is specifically Denied that she agreed to pay for her mother's nursing home bill, she agreed only to the terms of the terms of Exhibit B. 30. Admitted in part, Denied in part. It is Admitted that Defendant acted as her mother's Power of Attorney and that she had a fiduciary duty. It is also Admitted that the nursing home is a beneficiary party. It is Denied the implication that she failed to take actions required by the Agreement which included using her assets and resources to pay for nursing home care. Her actions are more particularly described in Paragraph 14. 31. Denied. It is Denied that Defendant breached a fiduciary duty to her mother. It is specifically Denied that she converted or fraudulently transferred her mother's assets or resources to herself. 32. Admitted in part, Denied in part. It is Denied that Defendant breached her fiduciary duties. It is Admitted that Plaintiff was the primary care giver for her day-to-day care. It is Denied that Defendant caused Plaintiff to incur damages as a result of her actions. WHEREFORE, Defendant prays this Honorable Court to dismiss the Complaint of Plaintiff, and award her counsel fees and costs for defense of this Complaint. ANSWER TO COUNT IV - CONVERSION 33. Defendant incorporates the contents of Paragraphs 1 - 32 of her answer as though set forth at length herein. 34. Denied. It is Denied that Defendant deprived her mother of her right in, use and / or possession of her property as set forth above. 35. Denied. It is Denied that Defendant converted, misappropriated or deprived her mother's right in, use and / or possession of her property for the purpose of hindering or delaying the transfer of any assets to Plaintiff acting as her Power of Attorney. 36. Denied. It is Denied that Defendant engaged in any unlawful actions causing damages to Plaintiff. WHEREFORE, Defendant prays this Honorable Court to dismiss the Complaint of Plaintiff, and award her counsel fees and costs for defense of this Complaint. ANSWER TO COUNT V - FRAUDULENT TRANSFER 37. Defendant incorporates the contents of Paragraphs I - 36 of her answer as though set forth at length herein. 38. Denied. It is Denied that Joanne Cooper transferred assets to Defendant or gave or caused Defendant to receive such assets for the purpose of hindering or delaying payment to Plaintiff. 39. Denied. It is Denied that Defendant received her mother's assets and / or resources, let alone for less than fair value or that it was to avoid payment of nursing home care or services to Plaintiff. WHEREFORE, Defendant prays this Honorable Court to dismiss the Complaint of Plaintiff, and award her counsel fees and costs for defense of this Complaint. ANSWER TO COUNT VI - EQUITABLE SUPPORT 40. Defendant incorporates the contents of Paragraphs 1 - 39 of her answer as though set forth at length herein. 41. Denied. It is Denied that Defendant transferred her mother's assets to herself or misappropriated any assets. 42. Denied. It is Denied that Defendant transferred or misappropriated the assets or her mother. It is Denied that Joanne Cooper was indigent. It is further Denied that her debt to Plaintiff could not have been paid through medical assistance. 43. Denied. The averment of Paragraph 43 is Denied as a conclusion of law. It is Denied that Joanne Cooper was indigent. It is Denied that 62 P.S. § 1973 requires that indigent parents be placed in a nursing home facility to be paid for by their children. 44. Admitted. 45. Denied. It is Denied that Defendant misappropriated her mother's assets. It is Denied that Defendant had the ability to satisfy her mother's debt, she is currently in a chapter 13 bankruptcy. 46. Denied. The averment of Paragraph 46 is Denied as a conclusion of law. To the extent it is factual, Defendant did not misappropriate any of her mother's assets. WHEREFORE, Defendant prays this Honorable Court to dismiss the Complaint of Plaintiff, and award her counsel fees and costs for defense of this Complaint. NEW MATTER 47. Defendant incorporates the contents of Paragraphs 1 - 46 of her answer as though set forth at length herein. 48. Defendant is bankrupt, having filed a chapter 13 petition in bankruptcy on July 30, 2003, docketed at 1-03-04483, and has been without the means to pay for her mother's care at all times relevant hereto. 49. Joanne Cooper's estate appears to have assets which require probate from the death of her spouse, Francis Cooper on October 19, 2000. 50. Defendant is forced to advance monies out of her own pocket to probate her mother and father's estate(s), which now must be delayed in defending against this suit. 51. Defendant advised Plaintiff's counsel that time would be required to administer the estate, but chose to file the instant complaint rather than permit probate. 52. It may be the case that Defendant can apply for medical assistance for her mother, when the required paperwork is completed which would be for the benefit of Plaintiff. 53. The payment of a debt from Defendant in addition to the above stated sums, would be a double recovery for the Plaintiff. 54. The defense of this matter, serves only to add expense to the estate of Joanne Cooper and deprive all her creditors of money which might be paid to Plaintiff. 55. The actions of Plaintiff are vexatious, obdurate and designed to overwhelm Defendant in her time of grief. WHEREFORE, Defendant prays this Honorable Court to dismiss the Complaint of Plaintiff, and award her counsel fees and costs for defense of this Complaint. 3904 Trindle Road Camp Hill, PA 17011 717-731-9502 Attorney for Defendant VERIFICATION I verify that the statements made in this Answer are true and correct, to the best of my knowledge, information and belief. I understand that any false statements herein are subject to the penalties of 18 Pa.C.S. §4904 relating to unswom falsification to authorities. Date: 9/15/05 \ . L ie C. Weller ID No. 77399 g i?-c3 E IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, 1000 Claremont Road Carlisle, PA 17013 Plaintiff V. Laurie C. Weller, 108 May Drive, Apt. #1 Camp Hill, PA 17011 Defendant No. 05-4126 Civil Term Civil Action Law CERTIFICATE OF SERVICE I certify that a true and correct copy of the foregoing document was served on the below persons by first class U.S. Mail, postage prepaid, or the means specified: Steven M. Montressor, Esquire Latsha Davis Yohe & McKenna, P.C. 1700 Bent Creek Blvd, Suite 140 Mechanicsburg, PA 17050 Date: 06 /V 3904 Trindle Road Camp Hill, PA 17011 717-731-9502 W No. //SyY n o O v> m _ I W C c . a J ?? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, Plaintiff No. 05-4126 Civil Term V. LAURIE C. WELLER, Defendant Civil Action Law REPLY TO NEW MATTER 47. This is an incorporation paragraph to which no response is required. 48. It is admitted that Defendant is bankrupt and filed a Chapter 13 Petition in Bankruptcy on July 30, 2003, docketed at 1-03-04483. It is denied that Defendant has been without the means to pay for her mother's care at all times relevant hereto. In particular, to the extent Defendant received or had access to her mother's assets, her mother's care could have been paid for out of those assets. 49. Denied. After reasonable investigation, Plaintiff is without information sufficient to form a belief as to the truthfulness of the averments in this paragraph. 50. Denied. After reasonable investigation, Plaintiff is without information sufficient to form a belief as to the truthfulness of the averments in this paragraph. 51. Denied. The Complaint had been filed prior to defense counsel's letter to the Plaintiff's counsel advising that time would be required to administer the estate. By 101664 way of further answer, the filing of the instant Complaint does not prohibit or interfere with probate of the estate. 52. Denied. While Defendant can apply for Medical Assistance benefits on behalf of Defendant's mother, the benefit period would only be retroactive to the first day of the month ninety (90) days prior to the application for benefits. Thus, benefits would not be awarded in this matter. By way of further answer, as alleged more fully in the Complaint, numerous benefit applications had been filed by the facility. Each of these applications was denied as a direct result of Defendant's failure to provide verification of her mother's income and resources as requested by both the facility and the Department of Public Welfare. As Power of Attorney, Defendant is the only person with access to these records, and accordingly the only person who could satisfy these requests. 53. Denied. There would be no "double recovery" for the reasons set forth in Paragraph 52 above. 54. Denied. This matter names only Laurie C. Weller as a Defendant. Therefore, the funds of the Estate of Joanne Cooper should not be expended to defend this matter. 55. Denied. The actions of Plaintiff are solely for the purpose of procuring payment from unresponsive Defendant, who failed to respond to any requests for payment or for documentation necessary to complete her mother's Medical Assistance application until the filing of this suit. 101664 WHEREFORE, Plaintiff Claremont demands judgment in its favor and against Defendant Weller in the amount of $69,010 plus interest, together with any other relief the Court may deem just and equitable. Dated: LO, 6. 0 r Respectfully submitted, LATSHA DAVIS YOHE & McKENNA, P.C. By: '41 Kimber L. Latsha, Esq. Attorney I.D. No. 32934 Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 (717) 620-2424 Attorneys for Plaintiff, County of Cumberland, Claremont Nursing & Rehabilitation Center 101664 VERIFICATION The undersigned states that he is the attorney for the Plaintiff, that he is authorized to make the within Verification, that the facts set forth in the foregoing Reply to New Matter are true to the best of his knowledge, information, and belief, and that this Verification is being made subject to 18 Pa. C.S. § 4904 relating to unsworn falsification to authorities. ??JJQ - Steven . ontresor Dated: (p. C, 0 3? 101664 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, Plaintiff No. 05-4126 Civil Term V. LAURIE C. WELLER, Defendant Civil Action Law CERTIFICATE OF SERVICE The undersigned hereby certifies that a true and correct copy of the foregoing Reply to New Matter has been served upon the person listed below via first-class mail, postage prepaid: Michael S. Travis, Esq. 3904 Trindle Road Camp Hill, PA 17011 [Attorney for Defendant] l Date: (o, G {.? Steven M. Montresor 101664 5 SHERIFF'S RETURN - REGULAR CASE NO: 2005-04126 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND CUMBERLAND COUNTY OF CLAREMONT VS WELLER LAURIE C BRIAN BARRICK , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon WELLER LAURIE C the DEFENDANT , at 1930:00 HOURS, on the 29th day of August , 2005 at 108 MAY DRIVE APT #1 CAMP HILL. PA 17 by handing to STEVE WELLER. HUSBAND a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 12.00 Affidavit .00 Surcharge 10.00 .00 40.00 Sworn and Subscribed to before me this day of j rJU A.D. Prctho ary So Answers: R_ Thnmaa Klina 08/30/20 LATSHA D By: IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, Plaintiff No. 054126 Civil Term V. LAURIE C. WELLER, Defendant Civil Action Law PRAECIPE TO SETTLE, DISCONTINUE AND END Kindly mark the above-captioned matter settled, discontinued, and ended. Respectfully Submitted, Dated: 3 - ;)0' a do F LATSHA DAVIS YOHE & McKENNA, P.C. By: Steven M. Montresor Attorney I.D. No. 74244 1700 Bent Creek Boulevard, Suite 140 Mechanicsburg, PA 17050 (717) 620-2424 Attorneys for Plaintiff, County of Cumberland, Claremont Nursing & Rehabilitation Center 122409 j . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTY OF CUMBERLAND, CLAREMONT NURSING AND REHABILITATION CENTER, Plaintiff V. No. 054126 Civil Term LAURIE C. WELLER, Defendant Civil Action Law CERTIFICATE OF SERVICE The undersigned hereby certifies that a true and correct copy of the foregoing Praecipe to Settle, Discontinue and End has been served upon the person listed below via first-class mail, postage prepaid: Michael S. Travis, Esq. 3904 Trindle Road Camp Hill, PA 17011 [Attorney for Defendant] Date: 3.2-0 • aovFS' Steven M. Montresor 122409 Ml UTI