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HomeMy WebLinkAbout05-5384 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTRY MEADOWS ASSOCIATES, a Pennsylvania Organization d/b/a COUNTRY MEADOWS OF WEST SHORE AT TRINDLE CORNERS Plaintiff, V. JOSEPH M. FELDISH, SR. and JOSEPH M. FELDISH, JR., Defendants. No. 05- g-3 04 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 OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013-3302 (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTRY MEADOWS ASSOCIATES, a Pennsylvania Organization d/b/ a COUNTRY MEADOWS OF WEST SHORE AT TRINDLE CORNERS Plaintiff, V. . No. JOSEPH M. FELDISH, SR. and JOSEPH M. FELDISH, JR., Defendants. CIVIL ACTION - LAW AVISO USTED HA SIDO DEMANDADO/A 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 veiente (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 objeccionee 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 reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued 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 O NO PUEDE PAGARLE A UNO, LLAME O VAYA A LA SIGUIENTE OFICINA PARA AVERIGUAR DONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Cumberland County Bar Association, 32 South Bedford Street Carlisle, PA 17013-3302 (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA COUNTRY MEADOWS ASSOCIATES, a Pennsylvania Organization d/b/a COUNTRY MEADOWS OF WEST SHORE AT TRINDLE CORNERS Plaintiff, V. JOSEPH M. FELDISH, SR. and JOSEPH M. FELDISH, JR., Defendants. No. 0s- 33FY (?cv 7;?- CIVIL ACTION - LAW COMPLAINT AND NOW, COMES, Plaintiff, Country Meadows Associates, a Pennsylvania Organization d/b/a Country Meadows of West Shore at Trindle Corners ("Plaintiff Country Meadows"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within complaint against Defendants, Joseph M. Feldish, Sr. ("Defendant Feldish, Sr.") and Joseph M. Feldish, Jr. ("Defendant Feldish, Jr."), and in support thereof, provides: 1. Plaintiff Country Meadows is a corporation organized and existing under the laws of the Commonwealth of Pennsylvania, with its principal offices located at 830 Cherry Drive, Hershey, Pennsylvania 17033. 2. Defendant Feldish, Sr. is an adult individual currently residing at Plaintiff Country Meadows' assisted living facility located at 4837 E. Trindle Road, Mechanicsburg, Pennsylvania 17050. 3. Defendant Feldish, Jr., Defendant Feldish, Sr.'s son, is an adult individual currently residing at 212 Market Street, Halifax, Pennsylvania 17032. 4. On or about June 18, 2004, Plaintiff Country Meadows and Defendant Feldish, Sr. entered into a written Admission Agreement ("Agreement"). A true and correct copy is attached hereto as Exhibit "A". 5. Pursuant to the terms and conditions of the Agreement, Plaintiff Country Meadows promised to admit Defendant Feldish, Sr. to its assisted living facility and provide him with assistance with daily living and related services in exchange for, inter alia, Defendant Feldish, Sr.'s promise to pay Plaintiff Country Meadows a specific monetary fee. 6. In accordance with the terms and conditions of the Agreement, Plaintiff Country Meadows provided Defendant Feldish, Sr. with the aforementioned assistance and services. In violation of the terms and conditions of the Agreement, Defendant Feldish, Sr. has failed to fully compensate Plaintiff Country Meadows for the aforementioned assistance and services that it has and continues to provide to him under the Agreement. COUNTI BREACH OF CONTRACT Plaintiff Country Meadows v. Defendant Joseph M Feldish Sr. 8. Paragraphs 1 through 7 above are incorporated herein by reference as if fully set forth at length. 9. Plaintiff Country Meadows and Defendant Feldish, Sr. entered into a written agreement, whereby Plaintiff Country Meadows agreed to accept Defendant Feldish, Sr. as a resident at its assisted living facility and provide him assistance with daily living and related services in exchange for Defendant Feldish, Sr.'s promise, inter alia, to pay a specific monetary fee to Plaintiff Country Meadows. See Exhibit "A". 10. Contrary to the express terms and conditions of the Agreement, Defendant Feldish, Sr. has failed to fully compensate Plaintiff Country Meadows for the aforementioned assistance and services that it has and continues to provide to him in accordance with the Agreement. 11. As a direct result of Defendant Feldish, Sr.'s breach of his aforementioned contractual duty, Plaintiff Country Meadows has incurred damages in an amount of $8,561.59 plus interest to date, future interest, attorney's fees incurred to date and continuing, in addition to the costs and fees as provided for in the Agreement. WHEREFORE, Plaintiff Country Meadows demands judgment in its favor and against Defendant Joseph M. Feldish, Sr. in the amount of $8,561.59 plus interest to date, future interest, attorney's fees incurred to date and continuing, in addition to the costs and fees as provided for in the Agreement. COUNTII BREACH OF STATUTORY DUTY OF SUPPORT (23 Pa.C.S.A. § 4603) Plaintiff Country Meadows v. Defendant Joseph M Feldish Jr. 12. Paragraphs 1 through 11 above are incorporated herein by reference as if fully set forth at length. 13. Defendant Feldish, Jr. is the son of Defendant Feldish, Sr. 14. At all times material hereto, Defendant Feldish, Sr. has been indigent. 15. At all times material hereto, Defendant Feldish, Jr. has possessed sufficient financial means to assist his father, Defendant Feldish, Sr., in paying for the care and services that Plaintiff Country Meadows has and continues to provide to Defendant Feldish, Sr. 16. At all times material hereto, Defendant Feldish, Jr. has had a statutory duty to support his father. 17. At all times material hereto, Defendant Feldish, Jr. has failed to provide financial support on behalf of his father. 18. As a result of Defendant Feldish, Jr.'s failure to financially support his father, Plaintiff Country Meadows has sustained damages in an amount in excess of $8,561.59, plus interest. WHEREFORE, Plaintiff Country Meadows demands judgment in its favor and against Defendant Joseph M. Feldish, Jr. in the amount of $8,561.59, plus interest. Respectfully submitted, SCHUTJER BOGAR LLC Dated: (p 07r By: !T i Y' i Chadwick . Bo r Attorney I. D. No. 83755 (717) 909-5920 Rodney Alan Myer Attorney 1. D. No. 89381 (717) 909-8160 441 Friendship Road, Suite 102 Harrisburg, PA 17111 Attorneys for Plaintiff 4 OCT-12-05 09:14 FROM-HOFAX2FL MUU-NU-L ...1? ..I -..._ VEIitF[CATION 7175331014 T-247 P.006/006 F-957 Me undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the best of his knowledge, information and belief. He understands that any false statements therein are subject to the penalties contained in IS Pa. CS.A. § 49M, relating to unworn falsification to authorities. I M1 S ` Dated- (o 41 Vincent J. M ak, icePresident Rx Oate/Time SEP-27-05 10:08 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 717533101a 7175331014 T-148 P.003 F-748 P. 003 .tRY M' 0 ; rTA;?4i ?0 % Retirement Communities it is a pleasure to welcome you to the Country Meadows assisted living community. These documents are known as "full disclosure" residential agreements. They are a good deal longer than other agreements, because they attempt to cover a multitude of possibilities that can occur when someone resides.with us. This agreement spells out as clearly and completely as possible the responsibilities that Country Meadows will undertake when you move into a Country Meadows community, your rights and responsibilities as a member of the Country Meadows community, the charges that you will receive for different types of services, and the circumstances under which your care may need to be changed in the future. We are honored that you chose Country Meadows. We look forward to serving you. This Agreement is made betvieen Country Meadows Associates (hereafter the "Community") and e.i'dc (referred to singly or ca ctively as "You"). . GENERAL A. The community is located at !l830E Timdl?Roaol,i'rledraailcsfou+? PA 170.60 (address). You have applied for accommodations at the community and the Community has accepted Your application. This Agreement is for accommodations and supportive services in: (check one) Basic Assisted Living O; William Penn (restorative assisted living) O; Meadows (memory support, assisted living in a secure environment) 01. Basic Assisted Living, William Penn and Meadows each have. two or three levels of service to assist You by providing the services that best meet Your changing needs. These are known as "enhanced" service levels. B. The Community is licensed by the Commonwealth of Peruasylvania, Department of Public Welfare, Division of Personal Care, as a Personal Care Home (assisted living facility). This Agreement is a self-renewing month-to-month Agreement that can be terminated as provided in Section VIII. AGREEMENTS 1. ACCOMMODATIONS AND SERVICES Beginning on 10 the Community agrees to provide the following accommodations and services for You, subject to the other terms, limitations and conditions contained in this Agreement. 1 Rx Date/Time SEP-27-2005(TUE) 09:38 7175331014 P.004 SEP-27-05 10:08 FROM-HOFAX2FL 7175331014 T-149 P.004 F-748 A. Accommodations Your Apartment. You may occupy and use Apartment No. 01-, subject to the terms of this Agreement. You are encouraged to personalize Your Apartment by providing some or all of Your own' furnishings. If You choose not to furnish Your Assisted Living Apartment, the Community will provide basic furnishings for Your Apartment. If You select an Apartment in the William Penn or Meadows Whig, the Community will provide basic furnishings for Your Apartment, which You are encouraged to partially personalize with Your own belongings. Exhibit "A" describes the Apartment You have selected. 21 Common Areas. You will be provided the opportunity to use the general- purpose areas of the Community, such as lounges, craft rooms, libraries, meeting rooms and chapel. Dining areas can be reserved to accommodate Your guests by giving notice at least one meal in advance of desired dining time. Guest meals will be charged as shown in Exhibit "°C" to this Agreement. 3. Decoration and Alterations. You are free to furnish Your Apartment as You wish, except for window treatments, provided that You comply with the safety rules o? the Community. You may not make any structural or physical changes to Your Apartment, unless expressly approved m writing by the Community. Any such alterations or improvements shall become the property of the Community. You may not change any lock or add any lock or docking device to Your Apartment without the prior written consent of the Community. Any changes or modifications to Your Apartment, which require the assistance of electricians, contractors or similar professionals, must be approved in advance by the Community. 4. Parking. Parking is available ifYou bring Your vehicle to the Community. If You operate or park Your vehicle on the premises, You agree to park the vehicle in an approved area, maintain the vehicle in operable condition, and keep current all registrations, licenses, inspections and insurance coverage required by law. B. Customized Services 1. Meals and Snacks. Three nutritionally balanced meals per day are included in Your Customized Service Rate. Also available are a Dental Soft Diet (i.e., food softened for dental reasons) and assistance in creating Your own selections from the Community's choices to meet Your dietary needs. Sugar-free desserts are offered for the convenience of residents dealing with diabetes and/or weight management. Snacks also are available to You and other Residents. You are responsible for self- managing any other dietary restrictions. 2 Rx Date/Time SEP-27-2005(TUE) 09:38 7175331014 SEP-27-05 10:08 FROM-HOFAX2FL 7175331014 T-148 P.005 F-T48 P. 005 2. Activities. The Community will provide a program of planned activities, opportunities for Community participation, and services designed to meet Your physical, social and spiritual needs. 3. Transportation. The Community will assist You in making arrangements for or provide transportation to meet Your medical and dental needs within a ten (10) mile radius of the Community or other prescribed range. The Community also will provide regularly Scheduled transportation services for use by Residents for shopping and other outings. A charge may be applicable, as provided in Exhibit "C" which lists charges for additional services. All other transportation is Your responsibility. C. Health and Personal Care Services 1. Observation. The Community, through its staff, shall regularly observe Your health status to identify changes in Your physical, mental, emotional and social functioning and will help You respond to Your dietary and health needs and needs for special services. In the event of an emergency, the Community staff will summon emergency medical services to assist You by calling "911," or otherwise summoning medical services personnel. 2. Irdtial and Annudl Medical Evaluation and Assessment. You agree to have an initial medical evaluation by Your physician, and annually thereafter, reported on a form provided by the Community. This evaluation shall be provided to the Community for retention with Your Resident record. . WithYour assistance, the Community staffwill prepare an initial assessment of Your needs and desires and develop Your Customer Service Summary. Other assessments may be prepared periodically at the discretion of the Community such as following a hospitalization, illness or injury. 3. Enhanced Services. The Country Meadows assessment evaluates the intensity and frequency of the services outlined in Basic Assisted Living, William Penn Assisted Living, and Meadows Assisted Living to determine if additional or enhanced support is required. To. meet those additional needs, the Community provides for two enhanced levels of personal care assistance, "Enhanced" and "Enhanced Plus," the charges for which are set forth in Exhibit "B." 4. Health Needs that the Community Cannot Meet. Should You need health services which cannot be provided in the Community, either by Community staff or outside healthcare providers with whom You contract, the Community will assist You in finding an appropriate healthcare facility. 5. Assistance with Personal Care Services. Through its staff, in the Community's most appropriate level, the Community will make available to You assistance with dressing, grooming, bathing, dining, medication 3 Rx 0at.e/Time SEP-27-05 10:06 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 P. 006 7175331014 T-148 P.006/045 F-748 management and other activities of daily living. The Community is unable to assist You in financial management other than by cashing small personal checks amounting to $50.00 or less. 6. Assistance with Ordering, Storing and Taking Medications. Alert pharmacy services, Inc. (Alert) is the preferred pharmacy for the Community. In conjunction with Alert, the Community will assist You m ordering and storing medications prescribed for self-administration. Medications are packaged in a Med-i-set container for safety-and ease of use. When the Community is responsible for assisting You with Your medications, for Your safety, both prescribed and over-the-counter medications will be stored by the Community rather than in Your Apartment. "Alert accepts and bills all pharmacy insurance plans that permit it to serve as a pharmacy provider for plan members. To determine whether Your insurance plan is covered by Alert, You should provide the Community a copy of the front and back of Your pharmacy plan or card, including the PACE Program. Mail order plans are accepted, subject to a service fee. While the Commimity encourages You to use the preferred pharmacy, You may request the use of an alternate pharmacy under the following conditions: (a) the Community's medications policies are followed; (b) medications are dispensed in Med-i-set containers and delivered weekly to the Community; (c) the pharmacy supplies a medication administration record (MAR) on a monthly basis that is kept current with Your prescription medications; and (d) the pharmacy bills You directly. You agree that failure of the alternate pharmacy to follow these policies may result in revocation of an exception by the Community by giving You seven (7) days' notice in writing. Requests should be submitted to the Administrator in writing. 7. Health Records. You authorize the Community to make available to its staff and agents on a need-to-know basis any personal or medical records prepared or maintained by the community. You also authorize the release of the records prepared by the Community to any other healthcare provider from whom You receive treatment and to third party payors of health services. The Community has a privacy policy that further outlines when and how Your health information is used. This policy is contained in a handout in Your admission packet. otherwise, Your records shall remain confidential and shall be made available only to You, Your authorized legal representative or authorized agents of the state or federal government, such as the Long Term Care Ombudsman. Except in accordance with Your express written consent, a subpoena, judicial order, 4 Rx Date/Time SEP-27-2005(TUE) 09:38 7175331014 SEP-27-05 10:09 FROM-HOFAX2FL 7175331014 T-149 P.007/045 P. 007 F-749 provider agreement or other applicable provisions of law, Your personal and health information will not be supplied to other than the aforementioned persons or entities. S. Excluded Services. In addition to the Community's charges, You are responsible for paying all legitimate fees and costs for goods and services furnished to or for You by anyone other than the Community unless covered in full by Medicare or other third party payors. You are obligated to pay such fees and costs whether the goods and services are furnished by someone referred by the Community or by a person or provider selected by You. These fees and costs are not included in Your Customized Service Rate. Fees for professional services rendered by a physician, therapy company or other service providers, including those covered by Paragraph VI (D), are not included in Your Customized Service Rate and will be charged directly to You by the healthcare provider. 9. Medicare Coverage. Whenever eligible for coverage, You agree to purchase Medicare Part B and Medicare Supplemental Insurance or HMO Medicare Coverage while a resident of the Community. II. FEES A. Customized Service Rate. The monthly Customized Service Rate is ($2(089 )( (pa 10)*, which applies to the service, level checked on Page One (1). This amount is due and payable one month in advance by the fifteenth (15th) day of each calendar month. Any balances unpaid within forty-five (45) days of the date of billing, including charges for services or supplies not included under the Customized Service Rate, will be assessed interest at the rate of one percent (1%) per month. Your rights to occupy and use Your Apartment and to receive other services under this Agreement are contingent on Your timely payment of Your Customized Service Rate. The items included in the Customized Service Rate are listed in Exhibit "B" to this Agreement. Charges for services or supplies not included in Your Customized Service Rate are listed in Exhibit "C." B. Adjustments to Rates. The.Community shall have the right, upon thirty (30) days prior written notice to You, to adjust Your Customized Service Rate and to amend other fees and charges. As otherwise provided in this Agreement, Your Customized Service Rate will be adjusted concurrently with any increase or decrease in Your level of service. C. Absences from Community. You are responsible for paying Your Customized Service Rate, even when You are absent from Your Apartment. When You are absent for five (5) days or more, The Community will deduct 5.00 per day from Your Customized Service Rate retroactive to the first day. Whenever the absence is due to medical needs, (i.e., skilled nursing or acute care) the Community will deduct $S.OO per day beginning with Your first day of absence. For Office Use Only - Accounting Charge Code 5 Rx Date/Time 5EP-27-2005(TIIE) 09;38 SEP-27-05 10:09 FROM-HOFAX2FL 7175331014 P.008 7175331014 T-149 P. 008/045 F-748 D. Community Fee. Prior to admission to the Community, You must pay a Community Fee. The Community Fee is used to help defray costs of entering and leaving the Community including cleaning and refurbishment of Your apartment, initial resident assessment,. customer service planning, and completion and processing of Your admission documentation. The Community Fee is $2,000 for a married couple and $1,500 for a single or unaccompanied resident. Upon Your discharge from the Community, for whatever reason, a portion of the Community Fee may be refunded to You. If You give the Administrator written notice of intent to leave or if You are asked to leave within seventy- two (72) hours of admission, You will receive a full refund of the Community .Fee; if You are discharged following a stay of more than seventy-two (72) hours but less than 90 days, You will receive a refund of $750; if You leave following a stay of 90 days or longer, the balance of the fee will be retained by the Community. Married couples are eligible for refunds when both residents have left the Community within the specified time period. Your length of stay includes the day of admission but not the day of discharge. So long as You continue to occupy an Apartment, temporary absence from the Community forfpersonal or medical reasons (e.g., taking a vacation or a hospital or nursing home stay) does not amount to discharge. Refund of Your Community Fee will be subject to payment of Your Customized Service Rate and all other applicable charges owed at the time of discharge. Refunds will be made within the period prescribed by state law or within thirty (30) days of the date Your apartment is vacated, whichever comes first. In the event that Your discharge from the Community coincides with Your admission to a Country Meadows long-term care facility on either the Bethlehem or South Hills campus, You will receive a standard refund of the Community Fee as described above. If You return to an assisted living Apartment following a stay in our long-term care facility, a second Community Fee will be waived. III. ADMISSION A. Non-discrimination Policy. It is the Community's policy to comply with all local, state and federal laws and regulations. The Community does not discriminate in Resident admissions on the basis of race, ancestry, color, religious creed, age, sex, handicap, disability or national origin, provided the Resident, in the sole opinion of the Community, can be cared for legally and responsibly. Suitemates in shared Apartments are selected according to sex and their cognitive and physical abilities. Otherwise, Apartment assignments and transfers, as well as Resident care, are carried out without regard to race, ancestry, color, religious creed, age or national origin. B. Accuracy of Admission Documents. You understand and agree that Your application, statement of finances, health history and medical report, 6 medications, personal interview, emergency information records, copies of RK Date/Time SEP-27-2005(TUE) 09:38 SEP-17-05 10:09 FROM-HOFAXIFL 7175331014 PA09 7175331014 T-149 P-009/045 F-748 Your Social security card, Medicare card and any pharmacy insurance plan or PACE card, if applicable, are a part of this Agreement. Any material misrepresentation or omission made by You as to Your financial resources or health history shall render this Agreement voidable at the option of the Community. You agree to submit updated copies of the above information from time to time as changes take effect. IV. CHANGE OF ACCOMMODATIONS A. Semi-Private Occupancy 1. Suitemates who Are Not Couples. The Community permits semi-private occupancy of selected Apartments. If You occupy the Apartment with a friend, relative or other suitemate, in the event of the transfer or death of one of You during the term of this Agreement, the remaining Resident may stay in the Apartment upon payment of the then current Customized Service Rate for "special private" occupancy of the Apartment or, upon acceptance of a suitemate, the Rate for shared occupancy. If the remaining Resident wishes to transfer to an Apartment designated for "private" occupancy, You may do so when one becomes available. The then current Customized Service Rate for private occupancy will apply. In the event that the Community is unable to provide a suitemate satisfactory to You after two tries, You shall have the option to occupy Your Apartment privately at the "special private" Customized Service Rate or to find, within two (2) weeks of notice to You, a suitemate who is suitable for Your level of service. 2. Married Couples. The Community encourages shared occupancy of Apartments by married couples. If You occupy the Apartment together, in the event of a change of service level or the discharge or death of one of You during the term of this Agreement, the remaining Resident may. remain in the Apartment. Your new Customized Service Rate will be based on "private" occupancy. li. When Community or State Regulations Require You to Move. The Community makes available to You independent living or personal care accommodations in separate wings or floors, either within this facility or an affiliated facility on the same Campus. Your application and Page One (1) of this Agreement indicate the Community's service level selected by You. When You need or desire personal care assistance not offered in the service level agreed upon byYou and the Community, such assistance may be available elsewhere within the Community. Following are descriptions of the various levels of service and when a transfer to another level of service is appropriate: 1. Independent Living. This level of service is not licensed by the Commonwealth of Pennsylvania. In independent living, the Community 7 Rx Date/Time SEP-27-05 10:09 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 P. 010 7175331014 T-149 P.010/045 F-149 provides You with the main meal daily, weekly light housekeeping of Your Apartment, scheduled transportation to medical and dental appointments and shopping, a social and activities program, and round-the-clock emergency response by a trained staff member. The person responsible for emergency response may be located in an adjacent building. When You need one or more of the types of assistance provided in another level of service for a period exceeding thirty.(30) days, it will be necessary for You to transfer to an Apartment in that level. Based on the extent of assistance needed and/or consideration of Your safety and well being, Your transfer could take place in less than thirty (30) days. Your level of service will be determined by a physical and cognitive assessment by the staff of the Community who will assist You in moving to an Apartment in the appropriate level. While the Community is providing these additional services, You will be charged accordingly, until such time as You move to the next level. 2. Basic Assisted Living. This level of service is licensed by the Commonwealth of Pennsylvania and provides three meals daily, as well as assistance with one or more of the following personal care services: • Personal Hy&ene • Tasks of Daily Living • Medication Management • Supervised Care When You need extensive assistance with any of the personal care services listed above, require routine assistance with ambulation, or require a more structured environment due to memory loss, it will be necessary for You to transfer to a higher level of service. The level of service required will be determined by a physical and cognitive assessment by the staff of the Community who will assist You in moving to an Apartment in the appropriate level. 3. William Pena. This level of service is licensed by the Commonwealth of Pennsylvania for personal care and provides all services offered in Basic Assisted Living along with the following. a higher level of support services including assistance with ambulation, dining, continency management, personal laundry, grooming, personal hygiene and restorative physical care. 4. Meadows. This level of service is licensed for Personal Care by the Commonwealth of Pennsylvania to provide supervised care in a secure setting. Those needing this level of service will exhibit a degree of memory loss and/or other cognitive deficit sufficient for their attending physician to order care in a secure physical setting. In such a secure setting, You will have access to and must enter a 3 or 4-digit code on a touch pad 8 mounted on the wall in order to leave the Meadows wing. When residing Rx Date/Time SEP-27-05 10:09 5EP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 P. 011 7175331014 T-149 P.011/045 F-748 on this wing, You are able to leave the secure section when accompanied by a friend, family member or staff member who is authorized to accompany You outside the wing. Also, You will have access to a yard with sidewalks during daylight hours except in inclement weather. In this level of service, the Community provides an services in Basic Assisted Living along with the following: a higher level of support services intended to assist You in participating in a ulfilltng social and activities program; management of continency and personal hygiene; and validation of Your feelings which can help to maintain self-esteem and avoid depression. 5. Long Term Care/Skilled Nursing Care. When You require skilled nursing, it will be necessary to transfer to a long-term care facility in the event these services cannot be provided at the Community by an approved Hospice or Home Health Agency. The need for a higher level of service will be determined by Your physician or by a physical and cognitive assessment by the staff of the Community who are available to assist You in finding an appropriate facility. . State regulations d0 not permit a personal care facility to care for residents who are permanently confined to bed, have a third stage decubitus (i.e., bedsore), or require a feeding tube (unless self-managed), intravenous therapy, or services on a routine basis normally provided by a long-term care fscility. Other conditions that could require a higher level of service include but are not limited to special dietary restrictions, dysphagia, unmanageable incontinency, contagious diseases or psychiatric conditions that are not manageable in a.personal care setting. On its South Hills and Bethlehem campuses, the Community has skilled nursing facilities licensed by the Pennsylvania Department of Health to provide sIdIled nursing care. As a resident of the Community, You would be offered priority admission to one of the facilities should You need this level of care and if an appropriate room is available. Please understand that the Community cannot guarantee Your admission, or date of admission, to one of its nursing centers, nor are You under any obligation to consider or use its nursing centers. requirements and determine a possible admission date. To be considered for admission, You should contact the Admissions Director of the appropriate facility in order to discuss admission 6. Choosing to Leave taw Community. Should You choose not to transfer to a higher level of service within the Community when Your assessment of physical and cognitive abilities indicates the need, the Community will attempt to support You in--house until You can make other arrangements. OrdinanlyYou have a period of thirty (30) days to make other arrangements 9 Rx_Oar,,e/Time SEP-27-05 10:10 SEP-27-2005(TUE) 09:36 FROM-HOFAX2FL 7175331014 7175331014 T-149 P. 012 PA12/045 F-749 from the date You are notified of the need for a higher level of service. However, where the community believes there is a significant risk of harm to You or other members of the Community, You may be asked to move immediately. During the interim, You will be charg¢d for the additional assistance You require. V. ACCESS To YouR APARTMENT The Community's staff may enter Your Apartment at reasonable times and for reasonable purposes, including inspection, maintenance and other services described in this Agreement. Every effort will be made to notify You when a Community employee will enter or has entered Your Apartment for non-routine events. In addition, a duly authorized Licensing Representative of the State Department of Public Welfare, after providing proper identification and stating the purpose of his or her visit, may enter and inspect the entire Community, including Your Apartment, at any time without advance notice. Vl. RIGHTS AND RESPONSIBILITIES A. Rules and Regulations and Other Exhibits. You agree to abide by and conform to the rules, regulations and policies as they now exist for the operation and management of the Community and such reasonable amendments to the above as the Community may subsequently adopt. A copy of the Community's Rules and Regulations is provided with this Agreement as ExhMit "D" and is incorporated by reference as a part of this Agreement. You also shall have the rights set forth in the Statement of Resident's Personal Rights, which is attached as Exhibit "E" and made a part of this Agreement. Exlu'bit "F," Personal Inventory of Belongings, is a form to assist You in planning what You want to bring with You. This is a record that would be helpful in the event You were to make a claim on Your insurance, should You choose to carry renter's insurance. It is not necessary to complete this form before signing this Agreement. It is a variable personal record, and You need only acknowledge that You received the form. Your Customer Service Summary, outlining the services.and support You need or request and which the Community agrees to provide, as well as Your Customized Service Rate, is attached as Exhibit "G." B. No Proprietary Interests. The rights and privileges granted to You do not include any right, title or interest in any part of the personal property, land, buildings or improvements owned or administered by the Community. Your rights are primarily for services, with a contractual right of occupancy. Nothing contained in this Agreement shall' be construed to create the relationship of landlord and tenant between the Community and You. C. Absences. You are free to leave the Community at any time You wish, unless You are in the Meadows area, but the Community is not responsible for any obligations or expenses incurred by You at such time. You agree to notify the Community in the event You plan to leave for an extended'period of time, eg. vacations or hospitalizations. 10 Rx..Odte/Time SEP-27-2005(TUE) 09:38 SEP-27-05 10:10 FROM-HOFAWL 7175331014 P. 013 7175331014 T-149 P.013/045 F-748 D. Emergency Care. In an emergency, You agree that the Community may engage any licensed physician to attend to You. You hereby authorize such physician to render all such medical care deemed necessary. r E. Resident Responsibilities. In order to maintain Your good health, be an active member of the Community, and promote the order and safety of Yourself and the Community, You agree to the following: to participate in all fire drills; to purchase and utilize Med-i-set containers for all Your prescribed medications; to comply with all published Community Rules and Regulations; to arrange for an annual medical evaluation or geriatric assessment; to arrange for appropriate evaluations of Your potential for physical, occupational and/or speech therapy when requested by the Community; to be inoculated for flu and' pneumonia unless advised otherwise by Your personal physician; to participate in the Community's Healthy Living Program that include educational and recreational activities; and to take meals routinely in the appropriate Community dining room to which You have been assigned. VII. THE COMMUNITY'S STAFF The Community agrees to,provide, at a minimum, the staff established by state regulations for Personal Care Homes in order to provide the support services as set forth in Your Customer Service Summary. This Summary is attached as Exhibit "G." While the Community attempts to have a licensed nurse on campus around the clock, this may not be possible due to illness, staff shortage or staffing priorities. At such times, a trained staff member will be in charge and a licensed nurse will be available by telephone. VIII. TERMINATION OF AGREEMENT A. By You. You may terminate this Agreement at any time, with or without cause, by giving thirty (30) days' written notice to the Community through the Community's Administrator. Your notice must identify the date when the termination is to become effective, which date must be at least thirty (30) days after the date of the notice. In addition, if You are transferred permanently to an outside facility because You need a level of care not. available at the Community, You may terminate this Agreement immediately upon vacating Your Apartrnent and removing all Your belongings from it- B. By the Community. The Community may terminate this Agreement at any% time, without cause, by giving thirty (30) days' written notice to You and Your responsible person, if applicable: In addition, the Community may" terminate this Agreement for reasons including, but not limited to, the following: Your failure to pay the Customized Service Rate or additional charges for services within forty five (45) days of the date billed; Your failure to comply with State or Local laws after receiving written notice of the alleged violation; Your failure to comply with the Community's Rules and Regulations as described in Section VI (A); a change in the use of the Community; or a 11 Rx-Date/Time 5EP-27-2005(TUE) 09:38 SEP-27-05 10:10 FROM-HOFAX2FL 7175331014 7175331014 T-149 P. 014 P.014/045 F-749 Siding by the Community that the Community is inappropriate for Your care. Notwithstanding the foregoing, the Community may terminate this Agreement at any time by giving You written notice to vacate immediately if You are engaging in behavior that is a threat to the melntal and/or physical health or safety of Yourself or others in the Community. If the Community should close to all Residents, the Community's Administrator shall submit to You a written statement of the intent to close and the projected date, at least thirty (30) days before closure. Copies shall be provided to You, to the Department of Public Welfare, to Your emergency contact or designated person, to any agencies which participated in Your referral to the Community, and to any agencies currently providing services ,to You. (This paragraph is required by sfate regulations.) C. Vacating the Apartment and Your Refund. Upon termination of this Agreement under Section VIII, other than by death, You or Your estate shall vacate Your Apartment, remove all of Your belongings from it, and return all keys to the Community. Until Your Apartment is vacated and all Your property is removed, You shall remain liable for paying the Customized Service Rate. After Your Apartment has been vacated, the Community may remove any of Your remaining belongingk and store them at Your expense. Any portion of the Customized Service Rate which has been prepaid for a period during which the Apartment is not occupied by You or Your possessions will be refunded to You. D. Termination of Agreement upon Death of Resident. The Community acknowlegdes and complies with the Elder Care Payment Restitution Act (Act 171 of 2002) which,establishes a manadatory refund policy for residents in the event of death while residing at a licensed personal care facility. In the event of death, Your estate, personal representative or guardian shall remain liable for payment of the Customized Service Rate, less the cost of "elder care services" until Your personal property has been removed from the Apartment. Elder Care Services are defined by law as "services or treatment provided to meet a consumer's need for personal care or health care, including, but not limited to, homemaker services, assistance with activities of daily living, physical therapy, occupational therapy, speech therapy, medical social services, home care aide services, companion care services, private duty nursing services, respiratory therapy, intravenous therapy and in-home dialysis and durable medical equipment services, which are routinely provided unsupervised and require interaction with the consumer." Elder Care Services do not include room and board charges. Following removal of Your personal property from the Apartment, that portion of Your prepaid Customized Service Rate related to "elder care services" will be refunded to Your estate, personal representative or guardian within thirty (30) days of the date Your personal property is removed. As provided in Act 171 of 2002, the Community must attempt to contact 12 Your representative or guardian within 24 hours of learning of Your death to Rw Oate/Time 5EP-27-2005(TUE) 09:38 7175331014 P.015 SEP-27-05 10:10 FROM-HOFAWL 7175331014 T-149 P.015/045 F-749 arrange for an inventory of Your personal property. Following the inventory, the Community may choose to store Your property or to leave it in Your Apartment. If the Community chooses to store the property, a fee cannot be charged If after thirty (30) days the personal property is. hot claimed and disposal is being considered, the Community must send a notice by certified mail to Your estate, personal representative or guardian giving another fourteen (14) days to claim the property. If still unclaimed after this period, the Community is permitted, but not required, to dispose of the property. Act 171 of 2002, permits a disposal fee to be charged by the Community. The above-described provisions of the Elder Care Payment Restitution Act apply only in the event this Agreement is terminated by death. They do not apply to those residing in Independent Living apartments or to a refund of the Community Fee described in Paragraph II D of this Agreement. E. Release from Obligations. Any termination of this Agreement under Section VIII shall terminate the Community's obligation to furnish accommodations and services to You. Upon payment of any refund provided for above, the Community shall be discharged from any further obligations to You or Your estate under this Agreement. _r UL LIABILITY FOR PROPERTY DAMAGE You agree to maintain Your Apartment in a clean, sanitary and orderly condition. You agree to reimburse the Community for repairs to Your Apartment and/or damage to carpeting, furnishings and fixtures in Your Apartment beyond ordinary wear and tear. X. RESPONSIBILITY FOR LOSS OF RESIDENT PROPERTY The Community is not responsible for loss of any property belonging to you due to theft or any other cause unless such loss is proven to have been caused by the negligent or intentional acts of the Community, its employees or agents. If You choose to purchase insurance to cover possible damage or loss of Your property, You shall be responsible for paying for and maintaining such insurance. The Community strongly recommends that You keep only small amounts of cash on hand; items of significant monetary or personal value should be kept under lock and key. The Community's Business Office is available to cash personal checks amounting to $50.00 or less. SI. ADVANCE DIRECTIVES It is the policy of this Community to accept Residents' advance directives. These include healthcare powers of attorney, living wills, doctors' orders regarding CPR, or other documents which describe the amount, level or type of healthcare You wish to receive at a time when You no longer can communicate those decisions directly to a doctor. Also included are documents in which You name another person who has the authority to make healthcare decisions for You. If 13 Rr_Date/Time SEP-27-2005(TUE) 09:38 SEP-27-05 10:10 FROM-HOFAX2FL 7175331014 7175331014 T-149 P. 016 P-016/045 F-746 You have executed any such documents, or if You execute any such documents while You are living at the Community, it is Your responsibility to advise Community staff of this and to provide a copy of any such documents to the Community. If You have such documents and You have provided a copy to the Community, the Community will make its best efforts to provide copies of these documents to healthcare professionals who may be called to assist You with healthcare. If You execute such documents and later revoke or change them, it is Your responsibility to inform the Community of such revocation or change. In the event You do not wish to receive cardiopulmonary resuscitation (CPR) in a medical emergency, You may purchase a "NO CPR" bracelet or necklace. The bracelet or necklace, engraved with Your name, is available through Alert Pharmacy Services and will help others be aware of Your wishes. xa. CAPACITY OF RESIDENT AND GUARDIANSHIP Should You become unable to understand or communicate healthcare decisions and be determined to be incapacitated by Your physician or the Community's Medical Director, the Community shall have the right to take the following steps in the absence of Your prior designation of a legal representative to act for You: commence a legal proceeding in a court of competent jurisdiction to judge Your legal capacity and, when appropriate, have the court appoint a guardian. The cost of the legal proceedings, including attorney's fees, shall be paid by You or Your estate. (Copies of powers of attorney documents should be provided to the Community upon adinission for Your health information file.) XiII. ENFORCEMENT OF THIS AGREEMENT Failure of the Community in one or more instances to insist upon Your strict performance of, observation of, or compliance with any of the terms and provisions of this Agreement shall not be construed to be a waiver or relinquishment by the Community of its right to insist upon strict compliance by You with all of the other terms and provisions of this Agreement. 7DV. ASSIGNMENT You agree not to assign Your interest in this Agreement. XV. FAMILY VISITS The Community encourages family and friends to visit You, subject to the Community Rules and Regulations. The Community encourages.regular family involvement with You and provides ample opportunities -for families to participate in activities at the Community. You may have visitors at any time. The Community asks that visitors and family members be considerate ofYour suitemate whenever applicable. Normal Business Office hours are 9:00 am. to 5:00 p.m., seven days a week. 14 Rx Date/Time SEP-27-2005(TUE) 09:38 SEP-27-05 10:11 FROM-HOFAX2FL 7175331014 7175331014 T-149 P. 017 P.017/045 F-748 RVI. GOVERNING LAW This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania and shall be biFiding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. XVII. SEVERAWLITY The various provisions of this Agreement shall be severable one from another. If any provision of this Agreement is found by a court or administrative body of proper jurisdiction and authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision had not been a part of this Agreement. XVIII. ATTORNEY'S FEES In the event any action is brought by either party to enforce or interpret the terms of this Agreement, the prevailing party in such action shall be entitled to its costs and reasonable attorney's fees from the non-prevailing party, in addition to such other relief as the court may deem appropriate. 3=. SUB1itITTING CONCERNS OR SUGGESTIONS i• The Community welcomes Your input on how we are doing and where improvements can be made. You or Your personal representative are encouraged to forward suggestions or concerns to the Administrator of the Community. Your suggestions or concerns can be communicated directly or mailed to the Administrator at the address for notices in Paragraph A on Page One (1) of this Agreement. You also are encouraged to participate in the Community's monthly Fireside Chats and any Customer Satisfaction Surveys, both of which provide an opportunity for Residents to make suggestions and to voice concerns. Our goal is to provide appropriate services for all Residents. There shall be no retaliation against a Resident or personal representative who submits a concern- XX. RELEASE OF LIABILITY It is the Community's policy that each Resident maintains his or her freedom and independence to the greatest extent feasible. Residents are encouraged to exercise judgment in decisions of everyday life and to make choices that enhance the fullness and quality of their lives. Concurrently, declines in function may occur that are gradual and not : apparent until an accident or injury occurs. You and the Community acknowledge that as a result of such declines, older adults are more likely to have accidents, such as falls, and are more prone to be injured. Recognizing this increased risk of accidents among older adults, You acknowledge that it is not possible for the 'Community to prevent all Resident fails and similar accidents that may be due to declines in strength and balance or loss of visual acuity. Further, You agree to release and hold 15 R.•0ate/Time SEP-27-2005(TUE) 09:38 7175331 Old P. 018 SEP-27-05 10:11 FROM-HOFAXZFL TIT5331014 T-148 P.018/045 F-748 the community harmless from accidents and injuries that result from Your decisions that exercise Your freedom and independence, in spite of the higher risk of accidents. NOTICES Notices required by this Agreement shall be in writing and delivered either by personal delivery or mail. If delivered by mail, notices shall be sent by U.S. Postal Service, with all postage and charges prepaid. All notices and other written communications required under this Agreement shall be addressed as indicated below, or as specified by subsequent written, notice by the party whose address has changed. A. IF TO COMMUNITY. Notices to the Cognnunity should be addressed to "Administrator," Country Meadows Retirement Community, at the address set forth under Paragraph "A" on Page One (1) of this Agreement- B. IF TO RESIDENT(S). Notices to the Resident(s) should be addressed as follows (if notices are to be directed to a Responsible Person and not to the Resident, please enter that person's name and address): MM. PERSON RESPONSIBLE FOR ADMINISTERING PAYMENT If someone other than the Resident will be responsible for administering payments for the Resident's stay at the Community, please enter that person's name and address. Please note that the Community will not attempt to impose a financial obligation on anyone other than the Resident or his or her estate. ==. ACT 171 CONTACT PERSON 16 For purposes of the E1derCare Payment Restitution Act (Act 171 of 2002), the contact person for the Resident will be the following (please enter that person's name and address)- M. 1?1G, ?{a,c I U RxD i+VLK, PP D f 4d.l i f j?6 PM (')03a- R,- Aate/Time SEP-27-2005(TUE) 09:38 7175331014 P. 019 SEP-27-05 10:11 FROM-HOFAX2FL 7175331014 T-140 P.019/045 F-745 XXYV. REVIEW BY YOUR ATTORNEY This is a contract. It has numerous provisions that affect Your legal rights. It is strongly recommended that You ask an attorney to review this Agreement before You sign it and answer any questions tou may have. XXV. VOLUNTARY AND AUTHORIZED EXECUTION By signing below, You and/or Your Responsible Person signify that You have read the terms of this Agreement, fully understand its terms, are voluntarily agreeing to those terms, and.iutend to be legally bound. If executing as Responsible Person, You hereby certify that You are authorized to sign on behalf of the Resident(s). IN WITNESS WHEREOF, the Community and You have executed this Agreement in duplicate. RFQIm1CMINS1I /Please "rind t By: Signature of Spouse, if applicable RESPONSIBLE PERSON, H applicable (Please prim: Name: du Date Address: v PC) 65X. G) o 9&11 QL<, P19 Telephone: &24o - D () 41 Relationship to Resident: 5471 Date `rHE COMMUNITY (Please print): Name: S4-&ren-Sowev-& Title: IN reciav of M&rkefq? By ?l?hct,u? P -4,wzN,? i o / i8/o ? Signature Date 17 Signature of Ifesident Date - _74 vin Curtis R. Long Prothonotary office of the Protbonotarp Cumberranti Countp Renee K. Simpson Deputy Prothonotary John E. Slike Solicitor 6,C- Q g y -CIVIL TERM ORDER OF TERMINATION OF COURT CASES AND NOW THIS 29TH DAY OF OCTOBER 2008 AFTER MAILING NOTICE OF INTENTION TO PROCEED AND RECEIVING NO RESPONSE - THE ABOVE CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA R C P 230.2 BY THE COURT, CURTIS R. LONG PROTHONOTARY One Courthouse Square - Carlisle, Pennsylvania 17013 - (717) 240-6195 - Fax (717) 240-6573