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HomeMy WebLinkAbout06-0808 , IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEAL THCARE CORP., d/b / a MANORCARE HEALTH SERVICES- CARLISLE, Plaintiff, No. a,. &'i$ c0j v. JIM FRALlSH, Defendant. CIVIL ACTION - EQUITY 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 clairns set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment rnay be entered against you by the court without further notice for any money claimed in the cornplaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights irnportant to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU 00 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 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 ORIGINAL IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEALTHCARE CORP., d/b/a MANORCARE HEALTH SERVICES- CARLISLE, Plaintiff, v. No. JIM FRALISH, Defendant. CIVIL ACTION - EQUITY A VISO USTED HA SlOO DEMANDAOO/ A EN CORTE. Si usted desea defenderse de las dernandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proxirnos veiente (20) dias despues de la notificacion de esta Demanda y A visa radicando personalmente 0 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 Ie 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 dernanda 0 cualquier otra reclarnacion 0 remedio solicitado por el dernandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero 0 propiedad u otros derechos importantes para usted. USTED DEBE LLEV AR ESTE DOCUMENTO A SU ABOGAOO lNMEDIATAMENTE. SI USTED NO TIENE UN ABOGAOO 0 NO PUEDE P AGARLE A UNO, LLAME 0 VA YA A LA SIGUIENTE OFICINA PARA A VERIGUAR OONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEAL THCARE CORP. d/b / a : MANORCARE HEALTH SERVICES - CARLISLE, Plaintiff, No. 0 L' .vb? tu:J !.tu-.. v. JIM FRALISH, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b / a ManorCare Health Services - Carlisle, ("Plaintiff ManorCareU), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Cornplaint against Defendant Jim Fralish, and in support thereof, provides as follows: 1. Plaintiff ManorCare is a Delaware corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 940 Walnut Bottom Road, Carlisle, Pennsylvania 17013. 2. Defendant Jirn Fralish is an adult individual, residing at P.O. Box 20, New Kingston, Pennsylvania 17072. 3. On or about August 1,2005, Defendant Jim Fralish rnade application on behalf of Jean Fralish, his wife, for admission to Plaintiff ManorCare's skilled nursing facility. 4. On or about August 1,2005, Plaintiff ManorCare and Defendant Jim Fralish, entered into a written Admission Agreement (a true and correct copy of the Admission Agreernent is attached as Exhibit U AU), pursuant to which ManorCare agreed to provide Jean Fralish with skilled nursing care and services in exchange for his promise to pay a specific monetary fee from Jean Fralish's assets, to make timely and proper application for Medical Assistance benefits, and to cooperate in that process by providing any and all financial records requested by the Curnberland County Assistance Office. A true and correct copy of the Adrnission Agreernent is attached as Exhibit" A." 5. Prior to Jean Fralish's admittance into Plaintiff ManorCare's skilled nursing care facility, she allegedly became insolvent. As a result, pursuant to the Agreement, an application for Medical Assistance benefits was filed on Jean Fralish's behalf. 6. The Application for Medical Assistance benefits was denied on Decernber 5,2005, due to Defendant Jirn Fralish's failure to provide documentary evidence to establish the eligibility of Jean Fralish for Medical Assistance benefits. (A true and correct copy of the denial [PA-162] is attached as Exhibit "B.") 7. Subsequently, Plaintiff ManorCare filed an appeal of the Cumberland County Assistance Office's denial of the above-referenced application for Medical Assistance benefits, and said appeal is currently pending before the Pennsylvania Bureau of Hearings and Appeals. 8. The application for Medical Assistance benefits referenced above will be denied unless Defendant Jim Fralish provides that information needed by Cumberland County Assistance Office to determine Jean Fralish's eligibility for Medical Assistance benefits. 2 COUNT I BREACH OF CONTRACTI SPECIFIC PERFORMANCE Plaintiff ManorCare v. Jim FraIish 9. The allegations contained in Paragraphs 1 through 8 are incorporated herein by reference as if fully set forth at length. 10. Defendant Jim Pralish breached the Agreement with Plaintiff ManorCare when he refused to make complete and proper application for Medical Assistance benefits when Jean Pralish qualified for such benefits, and Defendant Jim Pralish continues to breach the Agreernent with Plaintiff ManorCare by refusing to participate in the application process. 11. Defendant Jim Pralish's breach of the Agreement with Plaintiff ManorCare has caused and continues to cause irreparable harm. 12. Only a decree of specific performance will adequately protect the interests of Plaintiff ManorCare and provide it with the benefits and! or protections promised under the Agreement. 3 WHEREFORE, Plaintiff ManorCare seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, SCHUTJER BOGAR LLC Dated: 2 J t { Ob I BYC(, c. ~O \ b9~f Chadwick O. Bogar Attorney 1. D. No. 83755 (717) 909-5920 Christal 1. Hoo Attorney I.D. No. 200496 (717) 909-5922 305 N. Front Street, Suite 401 Harrisburg, P A 171 01 Attorneys for Plaintiff 4 OE[-~h~005IWEO) 11i,0~ P DOli/DOli VERIFICATION The undersigned hereby verifies that the statements of fad 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. CS.A. !i 4904, relating to unsworn falsification to authorities. Dated:~ O~~I Amy Marsh, irector of Fmance 5 2'd 7.00 . rl d~E:21 SO 60 uec v7.:jj INOW)QOO7.-60-NVr ,wl.I./'l"D xH , . EXHIBIT "A" " .,,-" HCR Manor Care Pennsylvania ADMISSION AGREEMENT This Agreement is entered into by and among Manor Care Health Services of Carlisle, d.b.a. HCR Manor Care ("HCR Manor Care"). the Resident, and the Responsible Party, if any, for the purpo se of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Center ("Center"). Center: MCHS-Carlisle Resident: Jean L. Fralish Responsible Party: James Fralish ~. @" , . r . D-~ .. '\~ , . Deposit: $ Q ~~ . rf~' \f ~ jPY^' This Agreement begins on the day the Resident enters the Center and ends on the day the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Resident's discharge date, 8/] /2005 Admission Date: Term: 1. RIGHTS AND RESPONSmILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident will pay the applicable Room and Board Rate set forth on Attachment A hereto, The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section will not apply if the Resident is covered under a governmental program (see Section 105) or by a third party payor or managed care organization (see Section 106). . 102 Ancillary Charges The Resident will pay to Center all charges for additional medical. therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such" Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges will be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. p'd VOO . rl eSO:Ol so 60 qa~ q\ :60 InH.I.)QOOZ-6n-R'I; '01.1./'1'0 XH '- 1.03 CollectionsfLate Pavments Payment is due in full within thirty (30) days of billing. Should the Resident's account for any reason be turned over for collection, the Resident will pay the Center's collection costs. including attorney's fees, 1.04 Independent Providers. The Resident is directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program, 105 Governmental Programs, If the Resident is eligible for coverage under any governmental program. such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center will accept payments under such program in accordance with the terms of the program as set forth in the contract the Center has with the program, The Resident is responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1,01 and 1.02. The Center participates in the following programs: _x_Medicare, _x_Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care, If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident agrees to pay any required deductible. any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. The Resident andlor Responsible Party are responsible for applying for Medicaid. If the Resident receives Medicaid. most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income The Resident agrees to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State andlor local department(s) handling Medicaid. If the Resident fails to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 106 Third Party Payors and Managed Care Organizations Ifa Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"). Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident is responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents, If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 S.d eSO'Ol 90 SO qa~ q\:nn (nH.l.lqnn7.-nn-R~,~ .mlJ./'\'n XH \ nn 'd -' ~ will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pav Resident. The Resident is responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for any governmental program or covered under any third party payor or managed care organization plan. The Resident and/or Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Responsible Party will notifY the Center in writing when application to Medicaid is made. The Resident and/or Responsible Party will cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf. the Resident wil1 be notified of the Center's intention to discharge the Resident for non-payment in accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Admission Information. The Resident and/or Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission and throughout the Resident's stay including copies of insurance cards. identification or verification of eligibility and coverage information. The Resident and/or Responsible Party will provide the Center in writing with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident acknowledges that if the Resident fails to provide such information, the Resident may be responsible for any denied charges due to Jack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 109 Application for Benefits. The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center has no obligation to bill any third party payor other than the Responsible Party and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1. 10 Primarv Responsibilitv for Pavrnent. Except for payments for services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily liable for any and al1 charges for which the Center may agree to bill a third party, The Resident and/or Responsible Party acknowledge that the insurance company, HMO, PPO. PSO, PHO or managed care provider may not pay for non-covered services. supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This agreement serves as a written notice that the Center has notified the Resident and/or Responsible Party that services provided at the Center may not be covered by a 3 9'd q nn ." ~SO:Ol 90 SO qa~ q~:6n InH,I,)Qnn7.-6n-HH aW1.J./aj'O xH ~ governmental payor, third party payor or managed care organization. The Resident and/or Responsible Party will be responsible for non-covered services A price list of services is maintained at the Center's business office and is available for review during regular business hours. 1.11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and abides by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician, If the Resident changes physicians at any time after admission, the Resident and/or Responsible Party must immediately notifY the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center will call another physician to attend to the Resident and the fees charged by such physician will be borne by the Resident. 1.12 Pharmacy The Resident and/or Responsible Party has the right to choose a pharmacy of choice. provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSIBILITY OF THE RESPONSIBLE PARTY 2 01 Legal Authoritv. The Responsible Party represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any. have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur personal financial liability on behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resources, 2.03 Requested Items. The Responsible Party will be personally liable for any services or products specifically requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds, If the Resident's financial resources change such that the Resident may be eligible for Medicaid. the Resident and/or Responsible Party must notifY the Center in writing and must promptly apply for Medicaid benefits If the Resident and/or Responsible Party fails to notifY the Center in writing or fails to file for Medicaid or provide such information as Medicaid representatives may require to qualifY the Resident for eligibility to Medicaid, the Center may end this agreement and transfer or discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if the Responsible Party fails to notifY the Center in writing or fails to file for Medicaid in a timely 4 L'd L 00 . d eSO'OJ SO SO qa~ 9\:60 InH11900Z-60-R~d am1l/al'0 XH ~ and proper manner, the Responsible Party will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Coooeration for Financial Assistance. If the Resident is eligible for Medicaid, the Responsible Party must provide such information about the Resident's finances as Medicaid representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation, If the Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid payments, and as a result Medicaid does not pay for the Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable notice for nonpayment, as provided in Section 4.06, 2,06 Acceptance U1)on Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the Center. If after notice, the Resident is not removed as requested. then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements and to pay promptly all charges. 2.07 Additional Responsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Resident Handbook. and Attachments. 2,08 Misuse of Resident Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding the Responsible Party's obligation to make payments on behalf of the Resident under Section 2,02 or for purposes of qualifying the resident for Medicaid eligibility, the Responsible Party may be liable to the Medicaid agency and/or the Center for care that should have been paid for from the Resident's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or civil sanctions against the Responsible Party, III. RIGHTS AND RESPONSffilLITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center will furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding. general nursing care, personal assessment. social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services, The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 5 8.'" 8nn .~ eSO:Ol SO SO qa~ g\:6n (nH.J.)gnnZ-6n-R~" 0.'.I.lo1'n XH . . 3,03 Deposit. The Center acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit will be applied to the charges for the first month of the Resident's stay at the Center. 3 04 Refunds, Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law, In the case of Medicaid Residents, any such refund will be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Responsible Party hereby consents to the release of the Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any person, firm, government entity, third party payor or managed care organization responsible for all or any part of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Responsible Party consent to the use and disclosure of Resident's protected health information for the purposes of receiving treatment from the Center, obtaining payment for healthcare services provided to Resident. and the Center's own healthcare operation needs. The Resident and/or Responsible Party, by signing this Agreement, authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies. as prescribed by the Resident's personal physician in the Resident's Plan of Care. or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Responsible Party represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identif'ying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identif'y the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Responsible Party acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Responsible 6 S'd fiOO . d eLO:Ot 90 SO qa~ g\:fiO (OH.J.)gOOZ-fiO-H," amlJ.lalen xH . . Party acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Assignment for Payment of Benefits See Attachment C. b, SNF Medicare Determination Notice, See Attachment D, c. Medicare Secondary Payor Questionnaire. See Attachment E. d. At the request of the Resident and/or Responsible Party. the Center will maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F-l and F-2. e. Center Supplement: 1. Policy and procedure on bedholds. election of bed holds and readmission. 2. Social Service Agencies and Advocacy Groups addresses and phone numbers. 3 Name, address and phone number of Ombudsman. 4, Location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. 5. The name, specialty and way of contacting the attending physician. medical director and other physicians who serve the Center. 6, Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. f The Resident Handbook. g. Resident/Patient Rights. h. Medicare!Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. 7 01 'd o TO . d eBO:Ol SO 60 qa~ Q\:fiO (OH.J.)QOO7.-fiO-R~d aW1.J./al'O xH . -- .~ Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment". which summarizes HCR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachments G-I and G-2. J. Privacy Act Notification, See Attachment H k. Notice ofInformation Practices and Receipt of Notice ofInformation Practices. See Attachments I-I and 1-2. 1. Ancillary Services Management Form. See Attachment 1. 4,05 Assignment of Benefits. The Resident and/or Responsible Party request that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1,06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf for any service furnished by or in the Center. The Resident and/or Responsible Party authorize the Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Responsible Party may terminate this Agreement by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Responsible Party or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnifY and hold the Center harmless from any and all claims. demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 8 II'''' II n 'J eGO'O! 90 GO qa~ g\:6n [nH.l.lgnn7.-6n-H~d "'.1./01'0 XH . . 4,08 Changes in the Law. Any provision of this Agreement that is found to be invalid or unenforceable as a result of a change in state or federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible. the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY QUESTIONS HAVE BEEN ANSWERED TO ~R SATISFACTION. ("-\~V n yO \.~ I \If'-- ,.' Signature of Resident _ / l..../ Date IOl 0 2.) Q) Signature of Responsible Party: Date: Center Representative: '-/~~ Date: (D/'-Iv-.~ 21 'd 7.1 n . d eSO'Ol SO SO qa~ q\:6n (nH.l)qnn7.-6n-R~~ oml.l./01'0 XH . ' . EXHIBIT "B" PA.!FS1U.oI-04 NOTICE TO APPLICANT BENEFIT O ASSISTANCE CHECK EllOlaLE El:reJlE PEM)ING 1...1U)O.~S9-DJ73 711-240-2700 DEPARTMENT OF PUBLIC WELFARE CUMBERU\HD COUNTY ASSISTANeJ; OfFICE 33 WESTM1NSTER DRlVE P. O. BOX 599 CAiRUSlE. PA 17013.0599 ~~t'!il~'_ . ~ . ~;\L~ I'~: ,; . Aher the IIrsl cheek whlcf1 may be 8 specla/8fYlount you wm rl'ceWe $, o Twicll a MonItI 0 OnclaMonl:h 0 InthllMaJ! 0 AtthllBank O MEDICAL . ASSISTANCE o You haYlIl!I palienl pay Mabnity 01 S lor the perlodtJellinnll1l1 O FOOD STAMPS o NURSING HOME CARE o ~~~~~S 0 ~T~~~r THIS: FOLLOWIN6.PERSONS ARE INCWOED U E NAME NO, You will recelve S a. mtlrrthIrom and en(j;ng lor l:he rnonlh(s) of 1hen you wfl! receive food sllImpsln the amCll.lllt 01 S 10 D)nltMM.aIJ o AtlhlBank o EtrecliW Dale llWelol care auUlOlized youaJ1;l e $ dtlowardyourearl1. AS. F 00 C~ECK STAMPS ME. ASST. s c. S RVIC€ L1N i< F 00 STAMP MED. ASST. s C. SERVICE l, ..f. 4-. <'A<>>1s. , tJ {'"r..",'f..' $ S't~- ~7-- J,...." ~ ~.e-.."J's .. Reason C~II Name Name TH Y ME S $ $ $ $ $ Name GROS MONTHLY UNEARNED INCO~ Nama u~~~~~~H6J S $ S $ $ $ TOTAl.. GROSS MONTHLY INCOME GROSS MONTHLY DePENDENT CARE COSTS GROSS MEDICAL COSTS S $ S TOTA\. GROSS MONTHlY INCOME GROSS MONTHLY DEPENDENT CARE COSTS $ $ Telephone WateltSewage Electric GarbagelTrash Gas Ulilityiqsta/latiorl on Other GRoSS UTIUTY COSTSIUTIUTY STANDARO. :; RENTIMORTGAGE $ TAXES S INSURANCE COST ON HOME $ TOTAL SHELTER COST S 7he househofd may swftch between th9 aclusJ utility .costs and the standard uU~ity allowance at the time of /'&application and one additional "time during saCh twelve-month period. o MEDICAL ASSISTANCE Name Number of Persons."" GA 55 MONTHLY EARNEQ NCOME $ $ $ Nama GR SOON HlY UN RNEO INCOME $ $ $ TOTAL GROSS MONTHt Y INCOM~ NEt MONTHLY INCOMEJNET SEMI.ANNl/AL INCOME INCOME LIMIT $ $ $ r )y~/ Wcrker's Signalllfe ~---. -~..,r~~ C/r"""'?" -9v""~ LU ;AM/ .., ~ ,:;/9/J-.;l74!:J Dale Tlillaphone Number LEGAL HELP IS AVAILABLE AT co RECORD NUMBER /di'"'57l' 21 LEGAL SERVICES, INC. a IRVINE ROW CARLISLE. PA 17013-3019 717-243-9400 717-76&ll475 .J Jf you do nor ~dersrand our decision or have any questions, contact your worker. 2"d _, ___ ~ftV dOO:2r SO BO ""U , ~ '\ -- ~ .,J ~ z ~ --.. --li;:,. "\ ( 'Jo. V'. '-"\ ., \,t,' \") , "'- l-. J lA ('\ ~ \') ~~ \ '\ ) ,,: f', "- ~\~ \ ~ ~~) ~:// o -...' :::-, C) -on ::;1 i--'i ,-,.... -,-, ; \ -c:::) 1 W \"'~ > - :~ ~'-' ---~ .' , . :, . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEAL THCARE CORP. djb j a : MANORCARE HEALTH SERVICES- CARLISLE, Plaintiff, No. 0[;" ~C{? tltJ v. JIM FRALISH, Defendant. CIVIL ACTION - EQUITY PLAINTIFF'S PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Plaintiff, Manor Healthcare Corp., djb j a ManorCare Health Services - Carlisle, ("ManorCare") pursuant to the provisions of Pa. R.c.P. 91531, and rnakes the following Petition for Preliminary Injunction and, in support thereof, avers: 1. On or about February 9, 2006 ManorCare filed its Cornplaint against Defendant Jim Fralish. 2. The Complaint sets forth a single claim against Defendant Jirn Fralish's relating to his breach of an Admission Agreement (" Agreernent"). See, Cornplaint, Exhibit" A" 3. The very nature of the breach of the Agreernent, i.e., Defendant Jim Fralish's refusal to rnake proper and complete application for Medical Assistance benefits on behalf of Jean Fralish, presents an issue of imrnediate and irreparable harm to ManorCare. 4. The requested injunction would restore the parties to the status quo as it existed imrnediately prior to Defendant Jirn Fralish's breach of the Agreement. ORIGINAL . ' I> 5. Greater injury would result from the denial of the requested injunction than frorn the granting of the sarne. 6. ManorCare's right to relief is clear. 7. ManorCare lacks an adequate remedy at law. 8. A bond in the arnount of $100.00 should be adequate in the event that it is later determined that the issuance of the instant Petition was in error. WHEREFORE, Plaintiff, ManorCare, respectfully requests that this Honorable Court schedule an immediate hearing on its request for injunctive relief, and thereafter issue a Decree ordering specific performance of the Agreement by and between the parties hereto. Respectfully submitted, SCHUTJER BOGAR LLC Dated: 2..- \ <( J 00 , { ~~a, be r By Chadwick O. Bogar Attorney J.D. No. 83755 (717) 909-5920 Christal 1. Hoo Attorney J.D. No. 200496 (717) 909-5922 441 Friendship Road Harrisburg, PA 17111 Attorneys for the Plaintiff FE OB-~OOD(WEO) 14:~O P. ODd/ODD VEIUFlCATlON The UI'ldcrsigncd hereby verifies that the statements of fact in the foregoing Petition for Preliminary II1junction are true and correct to the best of my knowledge, information and belief. I understand that any false statements therein aIe subject to the penalties cont3incd in 18 Pa. CS.A. !l4904, relating to unsworn falsification to 'lUthorities. j j -,1./' , ,." .' f Dated: ~~"y/ I '.. (/,I _'U/ , , /< /1/'", ' / /"1-~' -" _' j /r _,; .' By: , ~. /",,:. / ",U',/Yj Amy Marsh, Director of Finance 2"d 7. nn . rl e~O:Ot 90 SO qa~ q\:6n IOH.l.IQnn1-6n-H'l; .Wl.1'/.l_U x~ , . . . . . EXHIBIT "A" . . . . . . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP., d/b/a MANORCARE HEALTH SERVICES- CARLISLE, Plaintiff, v. No. JIM FRALISH, Defendant. CIVIL ACTION - EQUITY 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 rnoney or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU 00 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 S. Bedford Street Carlisle, P A 17013 (717) 249-3166 (800) 990-9108 , , IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP., d/b/a MANORCARE HEALTH SERVICES- CARLISLE, Plaintiff, v. No. JIM FRALISH, Defendant. CIVIL ACTION - EQUITY A VISO USTED HA SIOO 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 Dernanda y A viso radicando personalrnente 0 por rnedio 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 Ie advierte de que si usted falla de tomar accion corno se describe anteriorrnente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la dernanda 0 cualquier otra reclamacion 0 remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero 0 propiedad u otros derechos importantes para usted. USTED DEBE LLEV AR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO 0 NO PUEDE P AGARLE A UNO, LLAME 0 VA YA A LA SIGUIENTE OFICINA PARA A VERIGUAR OONDE PUEDE ENCONTRAR ASISTENCIA LEGAL. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 . . IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEAL THCARE CORP. d/b / a : MANORCARE HEALTH SERVICES- CARLISLE, Plaintiff, v. No. JIM FRALISH, Defendant. CML ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b / a ManorCare Health Services - Carlisle, ("Plaintiff ManorCare"), by and through its attorneys, SCHU1JER BOGAR LLC, and files the within Complaint against Defendant Jim Fralish, and in support thereof, provides as follows: 1. Plaintiff ManorCare is a Delaware corporation licensed to do business in the Commonwealth of Pennsylvania, with its principal offices located at 940 Walnut Bottorn Road, Carlisle, Pennsylvania 17013. 2. Defendant Jim Fralish is an adult individual, residing at P.O. Box 20, New Kingston, Pennsylvania 17072. 3. On or about August 1, 2005, Defendant Jim Fralish made application on behalf of Jean Fralish, his wife, for admission to Plaintiff ManorCare's skilled nursing facility. 4. On or about August 1, 2005, Plaintiff ManorCare and Defendant Jirn Fralish, entered into a written Admission Agreement (a true and correct copy of the Admission Agreement is attached as Exhibit" A"), pursuant to which ManorCare , . agreed to provide Jean Fralish with skilled nursing care and services in exchange for his promise to pay a specific rnonetary fee frorn Jean Fralish's assets, to make timely and proper application for Medical Assistance benefits, and to cooperate in that process by providing any and all financial records requested by the Cumberland County Assistance Office. A true and correct copy of the Admission Agreement is attached as Exhibit U AU 5. Prior to Jean Fralish's admittance into Plaintiff ManorCare's skilled nursing care facility, she allegedly became insolvent. As a result, pursuant to the Agreement, an application for Medical Assistance benefits was filed on Jean Fralish's behalf. 6. The Application for Medical Assistance benefits was denied on December 5,2005, due to Defendant Jim Fralish's failure to provide docurnentary evidence to establish the eligibility of Jean Fralish for Medical Assistance benefits. (A true and correct copy of the denial [P A-162] is attached as Exhibit URU) 7. Subsequently, Plaintiff ManorCare filed an appeal of the Curnberland County Assistance Office's denial of the above-referenced application for Medical Assistance benefits, and said appeal is currently pending before the Pennsylvania Bureau of Hearings and Appeals. 8. The application for Medical Assistance benefits referenced above will be denied unless Defendant Jim Fralish provides that information needed by Cumberland County Assistance Office to determine Jean Fralish's eligibility for Medical Assistance benefits. 2 . , COUNT I BREACH OF CONTRACT! SPECIFIC PERFORMANCE Plaintiff ManorCare v. Tim Fralish 9. The allegations contained in Paragraphs 1 through 8 are incorporated herein by reference as if fully set forth at length. 10. Defendant Jim Fralish breached the Agreement with Plaintiff ManorCare when he refused to rnake complete and proper application for Medical Assistance benefits when Jean Fralish qualified for such benefits, and Defendant Jirn Fralish continues to breach the Agreement with Plaintiff ManorCare by refusing to participate in the application process. 11. Defendant Jim Fralish's breach of the Agreement with Plaintiff ManorCare has caused and continues to cause irreparable harm. 12. Only a decree of specific performance will adequately protect the interests of Plaintiff ManorCare and provide it with the benefits and/ or protections promised under the Agreement. 3 . , WHEREFORE, Plaintiff ManorCare seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, SCHUTJER BOGAR LLC Dated: 2 I 't /Ob , r BYCC, c.lo \ bq~r Chadwick O. Bogar Attorney I. D. No. 83755 (717) 909-5920 Christal L. Hoo Attorney J.D. No. 200496 (717) 909-5922 305 N. Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff 4 . , aE(-cl-gaOS(WEDl 1&:02 p, 00&/006 . VERIFJCATION The undersigned hereby verifies that the statements of fad in the foregoing Complaint are tnle ~nd correct to the ~t of my knowledge. infonnalion and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C.S.A. 9 4904, relating to unsworn falsification to authorities. Dated:~ ~.~I Amy Marsh, ireclor of Fmance 5 2'd dl.E: : 21 SO SO uer . . '. . .'. EXHIBIT "A" . . , .-' '..r-' HCR Manor Care Pennsylvania ADMISSION AGREEMENT This Agreement is entered into by and among Manor Care Health Services of Carlisle, d.b,a. HCR Manor Care CHCR Manor Care"). the Resident, and the Responsible Party, if any, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor Care's Center ("Center"). Center: MCHS-Carlisle Resident: Jean L. fralish Responsible Party: James Fralish ~\l.. @" \ . t" . ~. II I. r Deposit: $ Q \\~ . aJl~' \f ~ jY"Y This Agreement begins on the day the Resident enters the Center and ends on the day the Resident is discharged unless the Resident is readmitted within fifteen (IS) days ofthe Resident's discharge date. 8/J /2005 Admission Date: Term: L RIGHTS AND RESPONSmILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident wilt pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section will not apply if the Resident is covered under a governmental program (see Section 1.05) or by a third party payor or managed care organization (see Section 1.06). . 1. 02 Ancillary Charges. The Resident will pay to Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such" Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges wilt be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate upon receipt. v.a ........... . . ~SO:OJ 90 60 qa~ Q(:,;n {(un \ Qnn7-"n_u'JJ !:JIII I I I... ~ .".... ,,,. '.~ 1.03 CollectionslLate .Pavments. Payment is due in full within thirty (30) days of billing. Should the Resident's account for any reason be turned over for collection, the Resident will pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident is directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center will accept payments under such program in accordance with the terms of the program as set forth in the contract the Center has with the program. The Resident is responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and I. 02. The Center participates in the following programs: _x_Medicare, _x_Medicaid and/or _VA. Medicare may pay for some or all of the Resident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other bjllable charges (which are not covered by Medicare Part A), the Resident agrees to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. The Resident and/or Responsible Party are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident agrees to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident fails to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Payors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident is responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 Sod ~so:or 90 SO qa~ nr'tn It\TI,lnnn... ,n ..... -' ~ will bill the Resident's third party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pav Resident. The Resident is responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for any governmental program or covered under any third party payor or managed care organization plan. The Resident and/or Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Responsible Party will notify the Center in writing when application to Medicaid is made. The Resident and/or Responsible Party will cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Admission Information. The Resident and/or Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission and throughout the Resident's stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Responsible Party will provide the Center in writing with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident acknowledges that if the Resident fails to provide such information, the Resident may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1. 09 Apnlication for Benefits. The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center has no obligation to hill any third party payor other than the Responsible Party and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primarv Responsibilitv for Pavrnent. Except for payments for services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Responsible Party acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered hy the Center or its subcontractors. This agreement serves as a written notice that the Center has notified the Resident and/or Responsible Party that services provided at the Center may not be covered by a 3 Sod "SO'OT SO 60 qa,J nf' 'cn '''''llnnn" cn ""1T ...,", , J....... vu . . , ~ governmental payor, third party payor or managed care organization. The Resident and/or Responsible Party will be responsible for non-covered services. A price list of services is maintained at the Center's business office and is available for review during regular business hours. 1.11 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and abides by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Responsible Party must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or tails to abide by applicable laws and regulations, the Center will call another physician to attend to the Resident and the fees charged by such physician will be borne by the Resident. 1.12 Pharmacv. The Resident and/or Responsible Party has the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state Jaw, abides by the Center's policies and procedures and has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. IL RIGHTS AND RESPONSffiILITY OF THE RESPONSffiLE PARTY 2.01 Legal Authoritv. The Responsible Party represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur personal financial liability on behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resources. 2.03 Requested Items. The Responsible Party will be personally liable for any services or products specifically requested by the Responsible Party to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Responsible Party must notify the Center in writing and must promptly apply for Medicaid benefits If the Resident and/or Responsible Party fails to notify the Center in writing or fails to file for Medicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibility to Medicaid, the Center may end this agreement and transfer or discharge the Resident for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid in a timely 4 /..'d ~so:or SO SO qa~ nf' . 1',., I "IT' \ n nn... "n ..... . . . . : . '- and proper manner, the Responsible Party will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2.05 Coooeration for Financial Assistance. If the Resident is eligible for Medicaid, the Responsible Party must provide such information about the Resident's finances as Medicaid representatives require for continued coverage of the Resident and he personally responsible for any charges denied the Center due to any lack of cooperation. If the Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid payments, and as a result Medicaid does not pay for the Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable notice for nonpayment, as provided in Section 4.06. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the Center. If after notice, the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements and to pay promptly all charges. 2.07 Additional Responsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Resident Handbook, and Attachments. 2.08 Misuse of Resident Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise illegally transfers assets for purposes of avoiding the Responsible Party's obligation to make payments on behalf of the Resident under Section 2.02 or for purposes of qualifying the resident for Medicaid eligibility, the Responsible Party may be liable to the Medicaid agency and/or the Center for care that should have been paid for from the Resident's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or civil sanctions against the Responsible Party. m. RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center will furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center will act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 5 B'd ~so:Ot SO SO qa~ t'lI"r:n In...lnnn.. I't'I n.... ....... J....~... .... ,. . -~ 3.03 Deoosit. The Center acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit will be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund will be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.0] Consent to Release ofInformation. The Resident and/or Responsible Party hereby consents to the release of the Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any person, firm, government entity, third party payor or managed care organization responsible for all or any part of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records, 4.02 Consent to Treat. The Resident and/or Responsible Party consent to the use and disclosure of Resident's protected health information for the purposes of receiving treatment from the Center, obtaining payment for health care services provided to Resident, and the Center's own healthcare operation needs. The Resident and/or Responsible Party, by signing this Agreement, authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including hut not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Responsible Party represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identifYing the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identifY the Resident. 4.04 Notice of Services. Policies and Additional Information. The Resident and/or Responsible Party acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Responsible 6 S.d "Lo:or 90 SO qa;j n r . 'n I nil I 'nnn'7 cn n'1_1 ,.,..., . /.. ~ ~" .... ~ . ~ Party acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Assignment for Payment of Benefits. See Attachment C. b. SNF Medicare Determination Notice. See Attachment D. c. Medicare Secondary Payor Questionnaire. See Attachment E. d. At the request of the Resident and/or Responsible Party, the Center will maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F -1 and F -2. e. Center Supplement: 1. Policy and procedure on bedholds, election of bedholds and readmission. 2. Social Service Agencies and Advocacy Groups addresses and phone numbers. 3. Name, address and phone number of Ombudsman. 4. Location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. 5. The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. 6. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident ahuse, neglect, mistreatment and misappropriation of property. f The Resident Handbook. g. Resident/Patient Rights. h. MedicarelMedicaid information and display of such information including how to apply for and use Medicare and Medicaid henefits, and how to receive refunds for previous payments. 7 Ot -d "80:0t SO 50 qa.:l _nr-co InllT\nnn'1 in n"1_1 . ~ . '- 1. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachments G-I and G-2. J. Privacy Act Notification. See Attachment H. k. Notice ofInformation Practices and Receipt of Notice of Information Practices. See Attachments I-I and 1-2. 1. Ancillary Services Management Form. See Attachment 1. 4.05 Assignment of Benefits. The Resident and/or Responsible Party request that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf for any service furnished by or in the Center. The Resident and/or Responsible Party authorize the Center and any holder of medical or other information to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third party payors any information needed to determine these benefits or benefits for related services. 4.06 Termination. Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Responsible Party may terminate this Agreement by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center filJs the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer hecomes necessary because the Resident and/or Responsible Party or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold the Center barmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 8 nod ~60:01 90 60 qa~ nr't.:n fnUlI0nn7_t.:n_o.,.t o:lm I . l'l~~" ..... . " . . 4.08 Changes in the Law. Any provision of this Agreement that is found to be invalid or unenforceable as a result of a change in state or federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY T,O ASK QUESTIONS AND THAT ANY QUESTIONS HA Vii: BEEN ANSWERED TO T R SATISFACTION, y' ycJ Cl n Vf'- " Signature of Resident f."'" ,) Ij Date: -iDI D 2..\ 0-5 Signature of Responsible Party: Center Representative: '----~ Date: Date: (D!7.-/tr,r- 210d '"SO'OI 90 SO q".:l or "1"1 fnUT\onn7_,n_O':lJ "'''' 1 I.........,. v.. ~ ~ . EXHIBIT "B" . - .-:'.,. P.....".ST62."'-04 NOTICE TO APPLICANT BENEFIT O ASSISTANCE CHECK a.lall3l~ EL~~JLe: PEl>IOIf'/G 1-800-269-0113 717-240-2700 DEPARTMENT OF PUBLIC WELFARt!. CUMBERlAND COUNTY ASSISTANCIE. OFFlCE 33 WESTM1NSTER DRIVE P. O. BOX 599 CARUSu" PA 11013-0599: ~.~~~,1~~(_ . ~ .\ . I \ ~I". . - . After ltIe W check which may be a spQdll.l''''OOf\t you wRI receive $ o Twice l Month 0 QnctaMcrnn D'"\tIBMall 0 At Ih& Banll; O MEDICAL ASSISTANCE o Vounaveapat\entp.lyliabllilyolS for tMperlodbegitmlng OFOOO STAMPS o NURSING HOME CARE o ~~Z~ES 0 ~THE,P, THE FOLLOWINS.PERSONSARE INCLUDED LINE NO. Vou'<'!inrecllve' arnonlhfrcm a1'ld~nding IOI'lhamornh!s)of It! Dlnlhlllolall o "EfteOiVlIOatlt 'hen you wllf receive /ood &ll!.mps In 'the lIrno\.lflt of $ o AIIh8 Bank l....e1 of care aulholi:zed !hlowardYOl.1(Cllrll. NAME AS. FOa M. DC. UN CHECK 51 AMPS AS i SERVICE NO. fOOO ME-D. STAMP ASST. s C. SERVICE 1-. " ReasonCodl t:J r,.J...,h ..Ie#",~.,... 6""",-c ~~~ . Name NumberofPer~" GAOSSMQNrnlY 'EARNEQ INCOMe Name S $ $ $ S $ Nama GROSS MONTHLY NEARNE INCOME Name >GROSS MI)',I Hl UNEAFtN IIINCOME S $ S $ $ S "TOTAL GROSS MONTHLY INCOME GROSS NlONTHlY' oePENDENT CARE COSTS GROSS MEDICAL COSTS " s s s TOTAL GROSS MONTHLY INCOME GROSS MONTHLY DEPENDENT CARE COSTS S $ Telephone Waterlsewage Electric GarbageITrasn Gas Utilityir,s13llatlon on Other GROSS UTfurv COSTSlUTIUTV STANDARO. :J RENT/MORiGAGE $ TAXES S INSURANCE COST ON HOME $ TOTAL SI:IELTER COST S 7tre household may sWitch between the actual utjJjty .costs and tl1e srandard utility allowance at the time of reapplicat10n and one additional "time during each twelve-month period. o MEDICAL ASSISTANCE Name Number of PeTSO!\S II'- GROSS 1M:! THl V EARN COME $ S S Name GAOS\;1l N HlY UNEARNED INCOME S $ $ TOTAL GROSS MONTHLY INCOME NET MONTHLY INCOME/NET SEMl-ANNUAlINCOME INCOME LIMIT $ $ $ co RECORD NUMBER /C/3!// /9"dff.r Worker's$1gnatUfEl ~ ,,;'44-,;2700 Dale TelQphone Number r %>t/ ...)~ M t:<j'4 -~..'/ ~e-.. ,?l/''j'f.PtqL-:' -9v<.l~ LU ;"U,G/ I LEGAL HELP IS AVAIl;,BLE AT 21 LEGAL SERVICES, INC. B IRVINE ROW CARLISLE, PA 17013-3019 717.243-9400 717.166-S475 .J I( you CIO not ~rstand our decision Of have any questions, COIlract your worner. _ ~ .1 ..,.. ._,.,. ""r-AI ..Jnn....... {: ( ~:~ ~, , , -'on '4 ~1- rTl I \J:; ,~ c. :-<. .. .' IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEALTHCARE CORP., d/b/a MANORCARE HEALTII SERVICES - CARLISLE, Plaintiff, v. JIM FRALISH, Defendant. AND NOW, this 111b-- No. {/0 -<ta' uiJ CIVIL ACTION - EQUITY ORDER , day of j- ~"'-G ' 2006, a hearing in the above-captioned matter on Plaintiff's Petition for the issuance of a Preliminary Injunction is scheduled for ~ ,;/J-. }.':)D ~.m. in Court Room No. , 2006, at 5 , Cumberland County Courthouse, 1 Courthouse Square, Carlisle, Pennsylvania. BY TIIE COURT: :7 i J. i ~\~\ '::-.I,.\.\,;:. (>- ~ t\ \ C) (' J" . ~...l s....) . ' c" \ \ ~'"J:J I \ L.. ".'\.\ '.,- .., ',", t} ~,~, '.(." f).: ------ \ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEALTHCARE CORP. d/b/a: MANORCARE HEALTH SERVICES- CARLISLE, Plaintiff, v. No, 06-808 JIM FRALISH, Defendant. CIVIL ACTION - EQUITY ORDER AND NOW, this I C ,~ day of ---.M o.H'~ , 2006, in consideration of the parties' Stipulation for Entry of Injunction, it is hereby ORDERED AND DECREED that: Within thirty (30) days of the date of this Order, Jim Fralish shall provide any and all verification requested by the Cumberland County Assistance Office to determine Jean Fralish's eligibility for Medical Assistance benefits and, further, take any and all other actions necessary to obtain said benefits on her behalf as requested by counsel for ManorCare, BY THE COURT ~ -L U~l\ ~ - \ \ J. ("q '.'.\ " \.: - IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a: MANORCARE HEALTH SERVICES- CARUSLE, Plaintiff, v, No. 06-808 JIM FRAUSH, Defendant. CIVIL ACTION - EQUITY STIPULATION FOR ENTRY OF INTUNCTION Manor Healthcare Corp. d/b/ a ManorCare Health Services - Carlisle ("Petitioner") and Jim Fralish ("Respondent") stipulate and agree to the following: 1. On or about February 9,2006, Petitioner filed a Complaint against Respondent. 2. The Complaint sets forth a single claim against Respondent relating to his breach of an Admission Agreement (" Agreement"), by failing to qualify his wife for Medical Assistance benefits and pursue the pending appeal of said denial. 3. The parties agree to the entry of an Order directing Respondent to provide within thirty (30) days of the date of the attached proposed Order any and all verification requested by the Cumberland County Assistance Office to determine the eligibility of Mrs. Fralish for Medical Assistance benefits and, further, to take any and all other actions necessary to obtain Medical Assistance benefits on her behalf as requested by counsel for ManorCare. A copy of that Order is attached as Exhibit" A."