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HomeMy WebLinkAbout06-2048 !I SHIPP ENS BURGI SOUTHAMPTON MANOR, L.P., Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v, NO, 2006- ;201../;Y CIVIL TERM DIANA CAIN and JOHN CAIN CIVIL ACTION-LAW I I' II I I I I I :1 I I I Defendants NOTICE You have been sued in court, If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served. by entering a written appearance personally or by an attorney and filing in writing with the court. your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAYBE ABLE TO PROVIDE YOU WITH INFORMA nON ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE, [I I I Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 (717) 249-3166 I, SHIPPENSBURGI SOUTHAMPTON MANOR, L.P" Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v, :) NO, 2006- dOL(! CIVIL TERM DIANA CAIN and JOHN CAIN CIVIL ACTION-LAW Defendants COMPLAINT NOW, comes Shippensburg/Southampton Manor, L.P" ("Shippensburg Health"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within Complaint and, in support thereof, sets forth the folJowing: I, Shippensburg Health is a Maryland Limited Partnership duly authorized to conduct business in the Commonwealth of Pennsylvania with a business address of 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257. 2. Defendant, Diana Cain, is an adult individual with a residence address of 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania 17257, II II I 3. Defendant, John Cain, is an adult individual with a residence address of7411 Lincoln Way East, Fayetteville, Franklin County, Pennsylvania 17222, 4, Shippensburg Health owns and operates a skilJed nursing facility located at 121 Walnut Bottom Road, Shippensburg, Cumberland County, Pennsylvania ("facility"). 5. On or about November 2, 2005, Diana Cain sought to be admitted to the Shippensburg Health facility. 1 ,I , ii 6. In connection with seeking admission, Diana Cain met with Shippensburg Health employees at the facility and executed an Admission Agreement. A true and correct copy of the Admission Agreement is attached hereto as Exhibit "A" and is incorporated by reference. 7, Diana Cain became a resident of the facility on November 2,2005 and remains a resident to the date hereof. 8, Pursuant to the Admission Agreement, Diana Cain agreed to pay from her own funds any costs of care not covered by a third party payor. 9. The Admission Agreement provides, in relevant part, as follows: If you or your representative do not pay the money you owe us and we hire a collection agency or attorney, you agree to be liable for their fees and court costs. 10, A true and correct Statement of Account reflecting the balance due Shippensburg Health for the costs of care provided to Diana Cain is attached hereto as Exhibit "B" and is incorporated by reference. COUNT I-BREACH OF CONTRACT SHIPPENSBURG HEALTH v. DIANA CAIN I 11. II at length. I 12. , fulfilled, 13. 14, Plaintiff incorporates by reference paragraphs one through ten as though set forth All conditions precedent to recovery under the Admission Agreement have been The amount due and owing is not covered by a third party payor. Diana Cain has breached the Admission Agreement by failing and refusing to pay for the service and care provided to him by Shippensburg Health, 2 ,I .1 , I I WHEREFORE, Plaintiffrequests judgment in its favor and against the Defendant for the sum of$21,370.00 plus late fees, interest, costs and expenses, attorney fees and any other amount coming due to the date of award, All in an amount not in excess of the limits requiring Compulsory Arbitration, COUNT III-SUPPORT SHIPPENSBURG HEALTH v. JOHN CAIN 15. Plaintiff incorporates by reference paragraphs one through nineteen as though set forth at length. 16. John Cain has been and is the husband of Diana Cain at all times relevant hereto, 21. Upon information and belief, John Cain has been and is of sufficient financial ability to financially assist Diana Cain in meeting the costs of her care. 22. Diana Cain, as a consequence of her failure to pay the amounts due and owing for her care appears to be indigent. 23. Pennsylvania statutes permit a court to direct the spouse of an indigent person to financially assist such indigent. 62 P,S. 91973, 24. The care and services provided by Shippensburg Health to Diana Cain are necessanes. 25. A creditor who has provided necessaries for the support or maintenance of a person may institute suit against that person's spouse for the price of said necessaries. 23 Pa. C.S.A. 94102, 3 II WHEREFORE, Plaintiff requests judgment in its favor and against John Cain in the 1 II I' 1\ I i amount of$21,370.00 plus interest, costs, expenses and any additional amounts coming due to the date of award, Respectfully submitted, EN, BARIC & SCHE~ I :!(t/L David A. Baric, Esquire J.D. 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 da b,dirlshcc/cain/complaint.pld i! VERIFICATION I verify that the statements made in the foregoing Complaint are true and correct to the best of my knowledge, information and belief. This verification is signed by David A. Baric, Esquire, Attorney for Plaintiff and is based upon the statements provided by Plaintiff, as well as documents reviewed by the undersigned as attorney for Plaintiff. This verification will be substituted and ratified by a verification signed by the Plaintiff who is presently unavailable to sign said verification, I undersigned that false statements herein are made subject to penalties of 18 P,o.S ~4904, ~I"i"g '" "~w"m "1"'''''''210 '"th","'~. ~ a David A, Baric, Esquire Dated: April 11, 2006 I II I , , I I ~ HEALTH CARE CENTER 121 Walnut Bottom Road Shippensburg, Pennsylvania 17251-g00S (711) 530-8300 FAX (711) 530-8304 TIY 1-800-654-5984 ADl\1ISSlON AGREEmNT This~eement.~etween Shippensburg Health Care Center (the "Facility" or ''wrf' and) 'd.,.,tA j -A .... . (the "Resident" or "you") and, if you or the court have designated an indivi<;iual to act on your behaJJ; or there is another individual to act on your be~ or operation oflaw, y'lliit ("your representativrf'). A checklist of the rights and respoosib' ties applicable to your representative is listed in Exhibit 1 and is incorporated into this Agreement. Pavilll!: for Your Care If you are applying to this facility as a private-pay resident, you must provide all financial infortnation requested by us. If we later find that the information you or your representative proVided was' incomplete or inaccurate; we will consider that as a breach of this Agreement which. gives us the right to pursue all legal remedies against you or your representative. Who Can Be Reauired to Pav for Your Care Only you and your insurer can be required to pay for your care, No other person. (Le, a family member, friend, neighbor, legal representative or guardian) can be required to pay from their own funds for your care,' although he or she may knowingly and voluntari1y agree to guarantee payment for the cost of your care, We require the person responsible for making payments on your behalf to pay for your care under the terms of this contract in a timely manner. If you are a beneficiary of Medicare, Medicaid or any other third-party payment plan, your representative agrees to make all necessary payments from your funds, Your representative could face a civil penalty for intentionally failing to pay required amounts from your funds and could face a criminal penalty for abusing your funds, Private Pav Resideuts The items and services included in our daily rate is basic room, board and general nursing care as required by your medical condition. Payment for items and services that are included in the daily rate and is payable one month in advance and due on the first of each month. Items and services included in your daily rate are listed in Exhibit 2.A. You will be charged separately for additional items and services not included in our daily rates such as special nursing care, special equipment, pharmacy charges, laboratOry charges, medical transportation and additional services such as telephone expense, dry cleaning, beal,lty and barber services and newspapers. Items and services for which you will be charged are listed in Exlu'bit 2.B. Payment for these additional items and services are due after you have requested them, and; . you bave received and have been billed for them. Within 30 days of receiving an item or service, ' EXHIBIT "A" If you or your representative do not pay the money you owe us and we hire a collection agency or attorney, you agree to be liable for their fees and court costs, . Private DutY NUrses Geriatric Aides If you want a private duty nurse or a private duty geriatric aide, you are responsible for selecting a person licensed andlorcertified according to Pennsylvania laws and regulations. You are also responsible for paying him or her and for letting us know that you have hired one. The person you hire is not an employee or agent of the facility, but he or she must meet our standards and follow our policies and procedures. . Employees of the Facility may' not serve as private duty nurses or private duty geriatric aides. . Holding Your Bed if You Leave the Facilitv If you are hospitalized or on leave from the Facility, we will hold your bed for you as follows: A. If you are private-pay resident, or are receiving inpatient care reimbursed under Medicare Program (and you are not covered under Medicaid), unless you notify us otherwise, we will hold yopr bed for as long as you pay for it at the daily rate you are currently being charged. B. If Medicaid pays for part or all of your nursing home care and you need to be hospitalized, we will hold your bed for up to the maximum number of days required by this state;'currently 15 days, If you leave for any other reason, we will hold your bed for up to the maximum number of days required by this state, currently 18 days. You have a right to be readmitted to the facility to the first available appropriate bed. While we are holding your bed, you are still required to pay the Facility any amount for which you are . liable as determined by the Medicaid Program. C, If you have applied for Medicaid, your bed will be reserved in accordance with Paragraph B, However, if you are found to be ineligible for Medicaid, then you are required to pay for the bed as a private pay resident as described in Paragraph A. D. Other third-party payers mayor may not have a bed hold policy. We will discuss this if it applies to you. Your Rigbt to Make Complaints and Suggest Cbanges in Policies and Services As a nursing home resident, you have many rights according to State and Federal law. These are described in detail in Exhibit 6, which is attached and is part of this Contract, You may make complaints about your care in the Facility and you may also suggest changes in the policies and services of the Facility, You will not be harassed or discriminated against for making a complaint or suggesting a change in a policy or service. You may present your complaints to facility, management company or to one of the folloWing State agencies: Larry D. Cottle, LNHA Administrator Shippensburg Health Care Center 121 Walnut Bottom Road Shippensburg, P A 17257 717-530-8300 . Peter E. Perini, Sf. President Magnolia Management, Inc. 1710 Underpass Way Hagerstown, MD 21740 301~745-8700 Ombudsman Office of Aging 16 West High Street Carlisle, P A . 17013 . 717-240-6110 717-532-7286 Ext, 6110 Department of Health 100 North Cameron Street . 2nd Floor Harrisburg,PA 17101 717-783-3790 Y QUI' Right to Make Decisions You have the right to make your own medical decisions and to m:inage your personal affairs, If you become disabled, it may be necessary for someone else to make decisions for you, For this reason, we recommend that you have a liVing will and/or advance directive for mellical decisions and a financial Power of Attorney' but you are not required to do so. See Exhibit 7 for a description of your legal rights to decide about your future medical treatment. Transfer. Relocation and DiScharge - You have the right to remain hen; and you may not be transferred, relocated or discharged against your will, except for the following reasons: (1) A medical reason (i.e. the facility carmot provide-the kind of care that you need, your condition has improved so that you no longer need the care we provide, or a medical emergency arises; (2) Your welfare or the welfare of other residents or staff; (3) Nonpayment for a stay, or (4) the Facility ceases to operate, If we decide that you should be transferred qr discharged, we will notify you, and an in;unediate family member or legal representative, by letter 30 days in advance, If you are transferred because of an emergency situation, we will provide the required notice as soon as practicable. The letter will contain the reasons for the transfer or discharge and its effective date. The letter will also tell you how you can appeal our decision to transfer or discharge you. If YOlJ, are discharged involuntarily, we will attempt to make other appropriate arrangements for your care. However, if other arrangements are not available, your representative agrees to accept you into his or her custody if it is medically appropriate, Your Ril!:ht to End This Contract Ifyau decide to .enQ this Contract and leave the Facility, you must pay your bill before you leave. . You must give us five (5) days written notice to terminate this contract. If you leave before the end of that time, you must still pay for each day of the required notice. ---, In. the event you die while a resident of the facility, your representative is responsible for making the funeral arrangements. We will notify your representative inunediately, If we .are unable to reach your representative, we will contact the funeral home of your choice to facilitate arrangements. Additional Docnments It is not possible to cover everything that is important to your stay in our Facility in the body of this Contract. Therefore, we have included additional important documents as Exhibits, These" Exhioits are part of this Contract. Please verilY that you received the Exhibits and that the contents of the Exhibits were explained to you by placing.your'initials on the line next to the description of each Exlnbit. tf2. f- Exhibit 1. Rights and Obligations of Representatives. /Ie Exhibit 2, For Private Pay Residents: (a) Items and services covered by daily rate. (b) Items and services not covered by daily rate. .~c LJ?c. Exhibit 3, How to Apply For and Use Medicare and Medicaid Benefits. Exhibit 4, (a) Items and Services Covered by Medicaid, (c) Items and Services Not Covered by Medicaid. JI~ -c... Exhibit 5. Physicians Who Practice at the Facility. [J c: Exhibit 6, Legal Rights of Pennsylvania to Decide Future Medical Treatment. lJlJ Exlnbit 7, Policies and Procedures Concerning Your Personal Funds and Your Personal Property, j) r , Exhibit 8. Services Provided by Outside Health Care Providers. Changes in Law Any provision of this Contract that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Contract. If there are services we have agreed to provide that are later found to be impossible to render asa result of a change in State or Federal law, it is agreed that to the extent possible, the Resident and the Facility will continue to fulfill our respective obligations under this Contract consistent with the Jaw, M IN WIl'NESS WHEREOF, the parties have executed this Contract on this 2J..., day of . AI.! r~ UtJ<)" . Witness By:. . L . D. Cottle, Administrator Shippehsburg.Health Care Center Ji::d~ L U.A"'~ C-t&:- Resident' If the Resident has been' adjudicated disabled or the Resident's doctor determines that the Resident is incapable of understanding or exercising his or her rights and responsibilities, the Facility may require the signature of another person on this contract. The other person may be: (1) An appointed healthcareagent under an advance directive'for medical care; (2) A guardian or Power of Attorney of the person; (3) A surrogate or family member. Responsible Party (Name) Witness Title: Indicate whether you are (1), (2) or (3) " I I EXHmITS TABLE OF CONTENTS Exhibit 1 Rights and Obligations of Representatives, Exhibit 2 For Private Pay Residents: A. Items and Services Covered by Daily Rate B. Items and Services Not Covered by Daily Rate, Exhibit 3 How to Apply For and Use Medicare and Medicaid Benefits. Exhibit 4 A. C, Items and Services Covered DY Medicaid, Items and Services Not Covered by Medicaid, Exhibit 5 Physiciails Who Practice at the FacilitY, Exhibit 6 Legal Rights of Pennsylvanian's to Decide About Future Medical Treatment. Exhibit 7 Policies and Procedures Concerning Your Personal Funds and Your Personal Property, Exhibit 8 Services Provided by Outside Health Care Providers, , EXHIBIT! RIGHTS AND OBLIGATIONS OF REPRESENTATIVE - The 'Representative shall have the right to be notified by the Facility of.any.event or, occurrence .. . <' 'involving the. Resident; -which directly affects 'any obligation' of the~Representative'.under this . Agreement. '.,,' Representative agrees to" assume" independently, .. under," this' 'Agreement: the' following; obligations and"is entitled to the following, rights/as indicated'by,'Representative's . initials accompanying any of the fo~owing provisions: ....~ . . e' Representative agrees to be' responsible for ensuring. that. any'payment<froIli' the"tesident to'. which the Facility is- entitled'pursuant' to. this Agreement shaU'..be>paid,t0.the:,Ea:eility in. a timely maimer, In the event the Resident is a beneficiary of Medicare, Medicaid or any other third-party payment plan, Representative agrees to ensure that all co-payments, co-insurance or charges and fees for non-covered items and services, together with any late fees as - described. under this Agreement,. shall be paid from the Resident's funds.. . Representative is subject to 'a'civil 'penalty-for wi11fu1.violation' of the'agreement~ocdistribute'the'Residenfs funds to the facility, .",/." · (Unless the Representative voluntarily agrees to act as guarantor), Representative shall be . responsible for, any payments required under this Agreement only to ,the extent. of the Resident's funds. , ., ResidenUs applying for admission on private pay. basis, and Representative. agrees to. assist the Resident in providing' all financial'information required by the Facility to determine the extent of the Resident's. resources. If it is ever determined the Representative participated in the disclosure of incomplete or inaccurate information, the incomplete or inaccurate disclosure shall be deemed a material breach of this Agreement and the Facility reserves the right to pursue all available legal remedies against the Representative, including but not limited to an action for breach of contract. · Representative is signing this Agreement as a duly authorized agent such as an appointed healthcare agent under an advance directive or guardian appointed by a court, A copy of all supporting documentation for this representation is attached to this Agreement. · Representative. is signing this. Agreement on Resident's behalf; based upon a physician's certificate, a copy of which is attached to this Agreement, certifYing that Resident does not possess the capability to understand his or her rights and responsibilities, · Representative agrees that in the event of the Resident's death, Representative shall take responsibility of all burial arrangements for the Resident and for removal of all personal property from the Facility. (Exlubit 1, Continued) · If it is the desire of the Resident or Representative to obtain the supplemental services of private duty nurses in accordance with the requirements descnbed under this Agreement, Representative agrees' to. be. responsible fol' arranging' independently for those services, including ensuring any payment. · ,Representative agrees. that in. the event the Resident's private funds .are'.exhausteddtiring the "'. ..'. Residenfs,stay and. the Resident is;eligible to apply for: benefitS under,.theMedicaid'Program, . the' Representative shall' assist the Resident and ..the" Facility'with <any" application for Medicaid benefits.... Representative. further..agrees to. act; fCi!i',beha1frofl the ',Resident, , to ,. ". fa.Ci1itateany Medicare; , Veterans Administration- or other..third"party. benefits, which. may be available to cover the cost of Resident' s care at the Facility. · In the event the resident seeks to terminate this Agreement, the Representative agrees to ensure that all notices required under this Agreement are provided to Facility, .. In the event of an involuntary termination of this Agreemertt,.. if., other 'arrangements acceptable to the Resident cannot be made, the Representative agrees to accept the Resident into the Representative's custody, if medically appropriate, .' Representative has. the right to copies of the following documents and any amendment to them Representative further' acknowledges receipt of the following documents, which may be amended from time-to-time, 1, A copy of this Admission Agreement. 2. A list of the Facility's rates, subject to amendment on'thirty-(30) days notice, and a description of charges for services not included, 3, A list of health care providers offering services at the facility. · Representative acknowledges the Facility's right to any legal remedies available under law for Representative's breach of this Agreement, , . EXHIBIT 2.A Private Pay Residents A. Items and Services Included in the Dailv Rate The items and services included in the daily rate, and their related charges, are listed below: Description of Items and Services Included in the Daily Rate 1. Room 2. Board 3, Social Services 4. Nursing Care, including: a, The ~timini!:f:ration of prescribed medications, treatments and diets. b, The provision of care to prevent skin breakdown, bedsores and deformities. c, The provision of care necessary to encourage the reSident from accident, injury and infection. d. The provision of care necessary to encourage, assist and train theresideut in self ..care and group activities. 5. Other: Activities Total Daily Room Rates (effective July 1, 2003) Special Care Program Semi-Private Rooms $179,00 $164,00 $152,00 $189,00 Private Rooms $184,00 Triple/Quad Rooms $174.00 Medicare co-pay: $105,00 ....""'- EX..HJ.H.IT 2.B ITEMS AND SERVICES NOT COVERED BY THE DAJLY RATE The following ite~ and services are not covered by the Facility's basic dai1y,rate: Item or Service Physician Services Medications Prescribed Dietary Supplements Personal Dry Cleaning, Personal Linens Tdephone Television Service BeautylBarber Shop Services Clothing Sundry Pharmaceutical Ambulance Service, Medical Transportation IV Therapy X-Ray Services Medical-Nursing Supplies Dental, Podiatrist and Opthamology Services Physical, Speech and Occupational Therapy Services Oxygen Newspaper, Periodicals Lab Services Specialized and/or specially ordered medical services/equipment Guest meals ...... -.- ".-" .----....-- (Exhibit 2,B, Continued) ITEMS AND SERVICES NOT COVERED BY THE DAILY RATE (refer to the Ancillary Charge List for additional costs) Item CharlZe . Telephone Direct bill from telephone company . Television/Cable per month . $7,00 per month ( . BeautylBarber Shop Services: Permanent $35,00 Haircuts and Blow-dry $10.25 Hair Sets $8,25 Cut Only $8,25 Color' $30,00 Personal Laundry $45.00 per month Personal Dry Cleaning Same as billed by clearier Physical Therapy Service Determined by level of care required Occupational/Speech Therapy' Determined by level of care required IV Therapy Charge list will be provided by contract pharmacy prior to delivery of services Aerosol Therapy Determined by level of care required ****~********************************~**************************************** Shippensburg Health Care Center cordially invites family members, guests and mends to join our Resident's at meal times, The prices for guest trays, effective July 1, 2001 are as follows: Breakfast A Breakfast B Lunch A Lunch B Dinner A Dinner B $4.00 $4.00 $4.00 $4.00 $4.00 $4.00 Will be served at 7:00 AM ($3,77 + ,23 state tax) served at 7:30 AM Will be served at 12:00 PM ($3,77 + .23 state tax) served at 12:30 PM Will be served at'5:00 PM ($3,77 + ,23 state tax) served at 5:30 PM *The Resident's will be assigned their meal times upon admission, Meals can be paid for at the Receptionists' desk. In order to prepare sufficient quantities we require a 2-hour notice to prepare guest tray, EXHIBIT 3 The following summarizes the Medicare and Medicaid programs, It also tells you who to call for more detailed information. If you have questions, our staffwill also help you. What's Covered - Medica1'e 1. Care in a hospital 2. 100 days of skilled care in a nursing home, Medicare provides fulh:overage fof'the first 20 days. You must make a co-payment after that. The-following services are. eXamples of skilled care: a. Injections & feedings given through an IV b. Tube feedings c, Application of a dressing that involved prescription medication d. Treatment of stage 3 or 4 bedsores 3, Medically necessary doctor's services, What's Covered - Medicaid Medicaid is a comprehensive program that will cover most of the costs 'of a nursing home stay, See Exhibit4 for information about covered and non-covered items., Your Contribution - Medicare .. Medicare does not pay 100% of the cost of covered services,.' Y ou'will be required to pay part of the charges. Your payment. may be called a "co-payment", "deductible" or ."premium", depending on the type of care provided. If you receive Medicaid, Medicaid will pay for any payment that you are responsible for under Medicare, Your Contribution - Medicaid. Depending on your income and assets, you may be required to make a contribution toward the cost of your care. The amount of any contribution will be decided by the local Board of Assistance, Who's EIil!ib'Ie - Medicare People 65 years old or.older'whoare eligible to collect old-age benefits under Social Security are eligible. PersonS who receive Social Security disability benefits for at least 24 months,' or have been found eligible' for Medicare-. by the Social Security Administration because they have end stage renal disease requiring regular dialysis or kidney transplant are also eligible. Who's Elie:ible - Medicaid. Eligibility depends on whether your income and assets are below certain levels: 1. Income: You should consult the local Board of Assistance to find out whether your income makes you eligible, That phone number is listed on the next page, If you qualify, $30 per month of your income is protected for your personal use while in the Facility, (Exhibit 3, Continued) 2. Assets: The Cumberland County Board of Assistance will also be able to evaluate your assets and tell you whether you qualify, The following are examples of things DQ! counted as assets, a. Your house if your spouse lives there. b. Household goods, c. A certain amount of cash, d, .. Personal Property in your possession in the Nursing'home. e, A certain amount of money for burial arrangements. How to Applv - Medicare Contact the local Social Security Office at the following address: Social Security Office 401 E, Louther Street Carlisle, PA 17013 (800) 772-1213 (717) 243-0085 How to ADDlv - Medicaid Contact the local County Board of Assistance at the following address: Board of Assistance 33 Westminister Drive Carlisle, PA 17013 (800) 269-0173 (717) 249-2929 . Whom to Contact if vou have a Ouestion or Problem - Medicare If Medicare denies a claim, you have the right to appeal the denial. You may appeal by writing to: Aetna Medicare Claim Administration 501 Office Center Building Fort Washington, PA 19034 (215) 643~7200 Whom to Contact ifvou have a Ouestion or Problem - Medicaid .. . If your application for Medicaid is denied, your coverage is terminated, or a service is not covered, you may appeal in writing to: County Board of Assistance Office 33 Westrninjster Drive P,O, Box 599 Carlisle, PA 17013 (717) 249-2929 (800) 269-0173 (Exhibit 3, Continued) Whom to Contact if vou have Incurred Mediul Emenses Drior to your MA Effective Date Medicare - Not 'applicable y.,. :',;~'v,Whom to,Contact if vou"have"Incurred' Medical.E:lpenses, prior to.vour~, Effective.nate, . ,..\ ", - Medicaid .' .... . .' ..' Medical bills .that you received in the 3 months prior. to' reeeiving:Medicaidtmay-be,'covered by Medicaid, Contact: County Board of Assistance Office 33 Westminister Drive P,O, Box 599 Carlisle, P A 17013 (717) 249-2929 (800) 269-0'173 EXHIBIT 4.A A. Items and Services Covered bv the Medicaid Per Diem Rate " ,...' Regular room; -dietary'services, social services and otheuervicenequired-w meet., . certification standards, medical. and surgical supplies;, and the use of equipment and facilities, . '. .:' ',.";. General nursing 'serVices,' including but not'limited.tO',",lidministra:tion,'o~;'9xygen , . ..'and' related:; medications; handfeeding, inc6ntinency..~care;1Iltrliy",'service', and enemas, . ".Basic Beauty/Barber Se!Yices; Th~ facility must provide'shampooing and hair care which is considered necessary for hygiene, the fucility" must inf6rilf the resident of the types and frequency of the services provided, . Items furnished routinely and relatively unifonnly ,to. .al1'.residents, stich. as water pitchers, basins, and bedpans. . Items .furnished, distributed, or used individually in':;small quantities such as alcohol, applicators, cotton balls, band-aids;'antacids;", aspirin "(and other . nonlegend drugs ordinarily kept on hand), suppositories;'aiId tongue' depressors. . Items used by individual residents but which .are reusable' and' expected to be available such as ice bags, bed rails, canes, crutches, walkers, wheelchairs, traction equipment, and other durable medical equipment, ," . Special dietary supplements used for tube feeding or oral feeding, such as elemental high nitrogen diets, even if written as a prescription item by a physician. . Laundry services for other than personal clothing. . Non-emergency'medical transportation services, . Other special medical services of a rehabilitative, restorative, or maintenance nature, designed to restore or sustain the resident's physical and social capacities, . Personal care items including a patient gown, shampoo, skin lotion, como, brush, toothpaste, toothbrush, and denture cream. EXBIBIT4.B B. Items and Services Not Covered bv the Medicaid Per Diem Rate . Medical expenses such as, but not limite(! to: . Health insurance premiums. . ,Visits by a non-participating, physician. other..than': appmved:"by:,the, nursing care facility. .....,. . '. Emergency. ambulance services, ,if the ambulance company d6e9'not accept'MA. . Over-the-counter medications, which are a particular brand not supplied by the nursing, facility, For example,. .the nursing facility must prbvide aspirin, but the patient:.may'request and buy a specific brand of pain reliever,' such . as.' Excedrin PM, or Tylenol. . Hearing aids and batteries, . . Specialized BeautylBarber Shop services. .. 'Diapers, if; the resident wants a style or brand.which, is, 'not, provided. by the nursing care facility, . Personal care items of the resident's choice ifhe prefers them instead of the items provided by the nursing care facility, This includes items such as brushes, combs, toothbrushes, cosmetics, etc, EXHIBIT 4.B . B. Items and Services Not Covered bv the Medicaid Per Diem Rate · Medical expenses such as, but not limited to: · Health insurance premiums, .., . .... 'Visits by a non-participating, physician' other..than"appmved"by,;the,'iJ.ursing care facility. . .,.." · '. Emergency. ambulance services, 'if the ambulance company doesinot accept<MA.. · Over-the-counter medications, which are a particular brand not supplied by the nursing, facility, For example, .the nursing facility must provide aspirin, but the patient:.may'request and buy a specific brand of pain re1ieveti.such 'as.'Excedrin PM, or Tylenol. . Hearing aids and batteries, · . Specialized Beauty/Barber Shop services, . . Diapers, if, the resident wants a style or brand.,whieh;,j~'not'provided. by the nursing care facility. · Personal care items of the resident's choice if he prefers them instead of the items provided by the nursing care facility. This includes items such as brushes, combs, toothbrushes, cosmetics, etc, .- EXHIBIT 5 PHYSICIANS WHO PRACTICE AT THE FACILITY Dr. YogindraS. Balhara, MD, 761 Fifth Avenue Chamber~burg, P A 17201 (717) 261-2583 ,Dr. William Kramer, M,D. 144 South Eighth Street . Chambersb\if&' P A 11201 (717) 264-6511 Dr.-Paul Orange, M,D, 4225 Lincoln Way East Fayetteville, PA 17222 (717) 352-3616 ..,., Dr,:;Ba'xtt~F Drew Wellrnon, IT, D,O., P.C, . 127 Walnut Bottom Road Shippensburg, P A 17257 (717) 532-3211 Dr.. Hong S. Paik, M.D. . 120NorthSeventhStre~ Chambersburg, FA 17201 (717) 267-7735 . EXHIBIT 6 LEGAL RIGHTS OF PENNSYLVANIANS TO DECIDE ABOUT HEALTH CARE . . Yon Have the Ri!!:ht to Decide About Your Health Care . . . '.. .,' ,'. .;".. Adults,generally'.have:'the- right- to. .decide if they' want'medical; treatment,.,uniess' they-are. not....:;:: . .. competent.\"This:rightincludesdecisions about treatments that, extend life;:life"supportmachines,. .'. or feeding tubes. ,,,' Sometimes; 'anaccident. or, illness .takes' away-a'person' s. abi1ity,.tmmake,health.'Cilr~.clJoire&, But-, _ . .,. . ";.the"decisionscstilVmust be made;", If, you.' are."unable,to:make:them;';Othe1lS~wi1kY'TheywiTh:decide ,..; '., ",:., based on your, wishes; .or your best interests if your wishes are,unknown, " ,. Pennsylvania law gives 'you the right to make many health care decisions'in advance, One way' , ,.. .. to do this is by using a written advance directive to name an agent to make your health care . decisions if you cannot, A written advance directive can also state your treatment preferences, especially about life sustaining procedures. NamiB!!: a Health Care A!!:ent You:can name'anyone to'be your health care agent. The"only"exception is' "that; ' in.. general, someone who works where you are receiving your care cannotbeyour agent. ' Your .agent ean be a family member or a friend, . . " . ,You'.choosewhen, your agent:can'decide for' you - right away; if'you'want; or; only' after two. '. doctors 'agree .that you are notable'to'decide for. yourself: .You' aiso'ichoose',the:kinds.'Of:decisions :. . your agent can-make for you:' For example" if you, want, you' can . give your agent very broad'. power to decide about life-sustaining treatment. Pick your health care agent very carefully.. Make sure your agent knows what you want. Your agent will then follow your wishes, even if your friends or family disagree, UsiB!!: Advance Directives There are many ways to use an advance directive, A living will is a type of written advance directive that states your wishes on life-sustaining treatments. It usually comes into affect when a person will die very soon from an incurable condition. It can also be used when a person is permanently unconscious (in a vegetative state). You can make a'broader.written.advance directive for other health care issues too, For example, you can decide whether you want life-sustaining treatment if you are in an end-stage condition:, An end"stage condition is an advanced, progressive, and incurable condition resulting in complete dependency. What Haooens HYou Dil Not Make an Advance Directive? No one can deny you health care because you do not have an advance directive, But you should know what happens legally if you do not, (Exhibit 6, Continued) Pennsylvania law allows a surrogate to make mediea1 decisions for you if you have not named a health care agent and are no longer able to decide treatment issues yourself. Then, your closest ,"" ':', relative. would be ~ked' io' make health', care' decisions 'for. yOu>.. :Y OUIt',spouse, 'aduit;children; ,'. ",' :' ,"'parents;o1"adult' brothers. and sister!; in that-order, are considered-yOUP.closest relatives:: If these , '" , ." re1atives,'are not available, another,relative Of' close mend:can 'make, decisions for ,.you.,.A -: . ..' " " . sUlTogate;; though,' .mightlmve. less. authority ,to: decide :against: life;,sustaining: proceduresi,than' a',.. ,." _ " health care' agent. . ' i'i.m.1here' is 'no one to be: a :surrogate, 'a' court, might have '.ta.',appoiBt'a'pdian"to:.inake"your' . "C , " . - ",.... ", medical decisions:' Theguardian,might'be.somebody who does<not:kno""'"you'personaRy-:,...;,' " . '... How DoYou Get More Information? Thissurnmary. does not cover every issue,' If you have legal questions about your rights, please ,'. speak ,to. a lawyer; , Also talk to your. health .care provider about. the;,medical, issues lmrolved in ". ,': :'\ ,; ,"."'"J'GUli,'careU 'Ie1kthose...caring for.you about your 'decisions- and~ye~themua'copy;;.m"aJl}l';advance ".; , , ''''. directive, For a free copy. of a Living Will or Advance Directive form contact: State Representative JefICoy 39 West King Street Shippensburg; P A 17257 ' (717) 532-1707 or Cumberland County Office of Aging Human Service Building 16 West High Street Carlisle, PA 17013 (717) 532-7286Ext, 6110 (717) 240-611 0 EXHmIT 7 POLICIES AND PROCEDURES CONCERNING YOUR PERSONAL FUNDS AND YOUR PERSONAL PROPERTY A Your Rights: ., '. L . 'You"have.therightto,keep and use your.' personal,:.,property,.: inaluding some , furnishings. and clothing, so long as there is enough:spaco.and;;other.[esidents are ' not inconvenienced, . You also have the' right" to security : for.. -your: -personal possessions. 2:..' " ,You' have'the'.rightto:manage'your financia1iftffiUfS>'llnless~a';cronrl\\1ieteimiile5, that you. are..', incapacitated ~ or' . the .' Social .', 'S~tyo.:.~atiot>>~,fflelt!cts a . representative to receive Social Security funds for your use and benefit. , " 3. We cannot require you to deposit your personal funds. with .us. You may, however, choose any person to manage your funds, including the Facility, 4, If you. decide to have us manage your'persorial.'funds;,you-may,withdraw'your ..'money., that ,we keep in the Facility'during.the~Facility~8"business"hourst,,'If we ,have deposited any of your funds in a bank,'y.o1l':maY obtain'those'funds within three banking days; provided the funds have cleared. . 5,' If you' .need. help to' perform . Y<JlU: banking-. rtransactionsii .you '\ may,: give the .administrator, of;ourFacility legal . authority. to',access' your': account. This authority,' is called "representative' payee:' To give the administrator this authority, you will need to complete a special form, 6, You and your personal representative have the right, during normal business hours, to inspect our written records that concern your personal funds, . 7, You and your personal representative have a right to file a complaint if either of you believes that your funds, valuables or' other assets have been stolen or damaged, The agencies to Contact in order to make a complaint are listed below: a, The Cumberland County Office of Aging Attn: Ombudsman Human Services Building 16 West High Street Carlisle, PA 17013 (717) 532-7286 Ext, 6110 (717) 240-6110 " (Exluoit 7, Continued) b, Cumberland County Board of Assistance 33 Westminster Drive . P.O. Box 599 Carlisle,PA 17013 (717) 249~2929 (800) 269-0173 c, .' The Department of Health Division of Nursing Care Facilities LOO North Cameron Street 2nd Floor Harrisburg, PA 17101 (717) 783-3790. B. Our Responsibilities: :, L' .... ~ . ,We; 'willA provide .a.reasonable 'amount of:"seeurc:.,spa'Ce;,[oui'}'ou.,-to,rkeep:'your "clothing. and other personal property.:' We mustinvestigatc:;.any;damage,to;'or loss of your personal property. . . 2,' :."~.,myou'want us to; manage' $50;00'.'OrAess'of'y.our,ipersOO,u~furidS'),we.will;deposit. . . ". . ..;thismoney-in,anon-interestbearingaccountoucapettycasllifund: " n' . ',' 3,.". . If',you:want'us :to" manage' more' than':$50;o.o.':of"'yo1l1":perSpjJ.abfundsp;we"wi11', . deposit this 'money. in an interest bearing account. that, is: insured by the:.federal government, This account will be separate from the accounts we use to operate the facility. In addition, we will credit you with all interest earned on your money. 4. We will maintain a full, complete and separate accounting of your personal funds. We will also provide you with a quarterly statement of the activity of your account. 5 If you' receive Medicaid benefits, we will notify yoil if your account balance becomes. too high, If you are to remain eligible for Medicaid, your account balance must be under a certain dollar limit that is established by the Federal government and changes periodically, . . 6. We may not use your personal funds to pay for an item or service that Medicare or Medicaid covers. 7, We will maintain adequate fire and theft coverage to protect your funds and personal property that are kept at the Facility, We shall also obtain a surety bond or otherwise assure the security of your personal funds that are deposited with the Facility. , ,. (Exhibit 7, Continued) 8. If you are discharged, there are several things we must do: a: . We will ensure the return of your personal funds. in our, possession, ,If we have deposited.your..personal funds.in a bank aceount"we;will'ensure, that " this: money is made available to you; or; . your ..authorized 'representative within 30 days, . . b.": ,'.If.we. are. your' representative payee::for~Bucial"Security, benefits;,..we. will . . promptly ask. the Social Security iAfuninistration": to,'n'am.e. a 'new .. .," '. representative payee andwewi1l transfer;'yoUt'inoneyto;that'persom... 9, In the event of your death, there are several things we must do: a, We will convey your personal funds and a final accounting cif those funds to thecperson.in charge ofadministering"your.:estate within.30 days. We wi1l;irnmediately notifyaily govemmerit,agency,thatipaitU'oraIVoIhpart. of your care in our Facility, That agency,-shall.have the right to assiSt us in '. determining what to do with your property, . b. .,' '; Ifa' govenunent 'agency did not pay' for. yOUI" care;' we..will.immediately c notify"your, representative or next of.lciruto .tieteflIl41e''what.to,do'.with. your . property, c, If we. have your funds, valuables or other. assets. in our possession, we will hold them until' the appointed personal representative of your estate presents a copy of the certified Letters of Administration to us. All conveyance of personal funds will be by check made payable "To the Estate of., , ", d. We will make reasonable attempts to locate your personal representative and your heirs, If no claim is made on your funds, valuables or other assets in our possession within six weeks of your death, we will write the State Office ofthe Comptroller for direction, 10, If we are in possession of your funds, valuables or other assets for more than one year from the date of your transfer or discharge, we will transfer your funds, any interest on your funds, and your valuables or other assets to the State Office ofthe Comptroller's Office of any account(s) in your name of which we have knowledge. , , .. EXHIBITS SERVICES PROVIDED BY OUTSIDE REALm CARE PROVIDERS ',.'. .',. " ;,.',Someofthe.servicesavailable.in the Facility; such'llS'pharmaC}tservicesrare.promdedj)y.outside" I ~:'hea1t:1rcai'e"providers:"These services; and information abotit.,theproviders;' appear- below.' You., . are free to pick your own provider or to use one of those listed below: " Type'ofService Physician X-Ray' Services Lab Services Pharmaceutical Podiatrist Podiatrist . ~ ..... 'w . " :" Whether we have Provider's N arne, .' a:iinanCial Address and . . '.' ,Interest in ~... ~ . Telephone Number . the Provider Dr. Y ogindra Balhara 761 Fifth Avenue No Chambersburg, PA 17201 (717) 264-6185 Mobil X-Ray Services The ChambersburgHospital No 112 N, Seventh Street Chambersburg, PA 17201 (717) 267-6356 The Chambers burg Hospital 112 N, Seventh Street No Charnbersburg, PA 17201 (717) 267-7153 Pharmacare Route 3, Box 3-A No Cumberland, MD 21502 (301) 777-1773 Dr. Peter Holdaway 1936 Scotland Avenue No Charnbersburg, P A 1720 I (717) 264-5211 Dr. Kirk Davis, D.P.M. 601 Wayne Avenue No Charnbersburg, PA 17201 (717) 267-2255 ... I~ " . (Exhibit 8, Continued) Tvpe of Service Dentist Hospital Inpatient or Emergency Room ~ .....'--,.., ... ~" Provider's Name, Address and Telephone Number Whether we have a financial . Interest in . the Provider Health Drive , 928Jaymor Road Si.1ite C-190 Southampton, PA 18966 (215) 942-9950 FAX (215) 942-9954 No Carlisle Hospital Chambersburg Hospital Fulton Co; Medical Center Hershey Medical' Center Waynesboro Hospital No No No No No Facility Phone: 117-530- . '. . SHIPPENS~URGHEAL TH CARECTR . 121 WALNUT BOTTOM RD SHIPPENSBURG, PA 17257 Resident: DIANA CAIN Statement Date: 02120/06 JOHN CAIN 7411 LWE FAYETTEVILLE, PA 17222 Date Service Through Qty Description Amount Sub Total as of 01/31/06 10,802.00 Charges 02/28/06 02/01/06 02/28/06 28 Room Charges Sub Total Balance 5,012.00 5,()12.()0 15,8H.00 .. -- Ancillary/Other Charges -,': ":--_h"':';"':". 02120/06 02/20/06 02/20/06 1 CABLE Sub Total Balance as of: 02/20/06 7.00 7.00 15,821.00 Proiected Prebill Charges 03/01/06 03/01/06 03/31/06 31 Prebill Room Charges Sub Total 5,549.00 5,549.00 21,370.00 Total Amount Due PAST PLEASE DUE REMIT . EXHIBIT "Bn Page 1 () "i>Cj- ^t~~ --:J fJ( ~ "6 \:> ~ 1; ~ ~ ",t- ('; (/\ - ~~ 0 ......~.~. lV') --...J " " 'j t,_> -. SHIPPENSBURGI SOUTHAMPTON MANOR, L.P" Plaintiff v. DIANA CAIN and JOHN CAIN Defendants IN THE COURT OF COMMON PLEAS or CUMBERLAND COUNTY, PENNSYLVANIA NO. 2006-2048 CIVIL TERM CIVIL ACTION-LAW PRAECIPE TO ATTACH SUBSTITUTE VERIFICATION Please attach the following Substitute Verification to the Complaint filed in this mattef on April II , 2006, \ I I I I , i I Date: April 18,2006 I I' 1\ I I da b.dir/shcc/cain/su bstitu tedverification. pra Respectfully submitted, O'BRIEN, BARIC &/i,,'CHE ER [, t:: ' David A. Baric, Esquire I.D. # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 I ii , VERIFICATION I, Larry Cottle, verify that the statements made in the foregoing Complaint are lrue and correct to the best of my knowledge, information and belief. I hereby ratify the verification previously supplied by my attorney, David A. Baric, Esquire and execute this verification as a substituted verification, I understand that false statements herein are made subject to the penalties of 18 Pa,C,S. 94904 relating to unsworn falsifications to authorities. Date: I~ j; 2~)( jU;: Ir arry ottle, Administrator S ppensburg/Southampton Manor, L.P, I I i :1 II I I I . II -. CERTIFICATE OF SERVICE I hereby certify that on April 18,2006, I, David A. Baric, Esquire of O'Brien, Baric & Scherer, did serve a copy of the Praecipe To Attach Substitute Verification, by first class U.S, mail, postage prepaid, to the parties listed below, as follows: Diana Cain 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257 John Cain 7411 Lincoln Way East Chambersburg, Pennsylvania 17201 David A. Baric, Esquire I I I I I II I I, ii II II -' ,. , ".,.. .-- ,'.,' II "- I' ~ v, < , , IN THE COURT OF C<bMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO, 2006-2048 CIVIL +ERM SHIPPENSBURGI SOUTHAMPTON MANOR, L.P" Plaintiff DIANA CAIN and JOHN CAIN CIVIL ACTION-LAW Defendants PRAECIPE TO ENTER DEFAULT JUDG ENT PURSUANT TO Pa.R.C.P. 1037 TO THE PROTHONOTARY: Please enter judgment in favor of the Plaintiff, Shippensburgl outhampton Manor, L.P, and against the Defendants, Diana Cain and John Cain, for failure to Ie an answer to the I Complaint of Plaintiff. I A true and correct copies of the Notices of Default are appendt hereto as Exhibit "A," A true and correct copies of the Certificates of Mailing for the otices of Default are I appended hereto as Exhibit "B," I certifY that the Notice of Default w+ given in accordance with Pa,R,C,P, 237,1. II Plaintiff requests judgment in the amount of $21,370,00 as set ~rth in the Complaint plus , < attorney fees of$650,OO and costs of$255,OO for a total of$22,020,oo,1 Respectfully submitted, I David A, Baric, Esquire LD, # 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 , L v, , I IN THE COURT OF CbMMON PLEAS OF CUMBERLAND COuNTY, PENNSYLVANIA I I NO, 2006-2048 CIVIL fERM I I CIVIL ACTION-LAW, SHIPPENSBURGI SOUTHAMPTON MANOR, L.P" Plaintiff DIANA CAIN and JOHN CAIN Defendants TO: Diana Cain 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257 Date of Notice: May 12,2006 IMPORT ANT NOTICE YOU ARE IN DEF AUL T BECAUSE YOU HAVE FAILED 0 ENTER A WRITTEN d APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE WRITING WITH THE 'i COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS S T FORTH AGAINST Ii YOU, UNLESS YOU ACT WITHIN TEN DAYS FROM THE DA T OF THIS NOTICE, A ',j Ii JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A HARING AND YOU i MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHT , YOU SHOULD TAKE I] THIS NOTICE TO A LAWYER AT ONCE, IF YOU DO NOT HA V ALA WYER OR ,i CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLO ING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP, :j I I! i " I) Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone: (717) 249-3166 ii Ii ii Ii Ii II II ,I 'I 1\ 'I I I, 1 ~15i: David A, B ric, Esquire 19 West So th Street Carlisle, P 17013 (717) 249-6 73 EXHIBIT "A" I 1 I I II <, SHlPPENSBURGI SOUTHAMPTON MANOR, L.P., Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COuMTY, PENNSYLVANIA v, NO, 2006-2048 CIVIL llERM DIANA CAIN and JOHN CAIN CIVIL ACTION-LAW Defendants TO: John Cain 7411 Lincoln Way East Fayetteville, Pennsylvania 17222 Date of Notice: May 12,2006 IMPORTANT NOTICE I I YOU ARE IN DEFAULT BECAUSE YOU HAVE FAILED 110 ENTER A WRITTEN APPEARANCE PERSONALLY OR BY ATTORNEY AND FILE INI WRITING WITH THE COURT YOUR DEFENSES OR OBJECTIONS TO THE CLAIMS S T FORTH AGAINST YOU, UNLESS YOU ACT WITHIN TEN DAYS FROM THE DA T OF THIS NOTICE, A JUDGMENT MAY BE ENTERED AGAINST YOU WITHOUT A H ARING AND YOU MAY LOSE YOUR PROPERTY OR OTHER IMPORTANT RIGHT , YOU SHOULD TAKE THIS NOTICE TO A LAWYER AT ONCE, IF YOU DO NOT HA V A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE FOLLO .ING OFFICE TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 32 South Bedford Street Carlisle, Pennsylvania 17013 Telephone: (717) 249-3166 David A, aric, Esquire 19 West S uth Street Carlisle, P 17013 (717) 249- 873 .. MAY BE USED FOR DOMESTIC AND INTERNATIONAL MAll,.. DOES NOT PROVIDE FOR INSURANCE-POSTMASTER '" '" '" '" ~ilJ ~, "~ i~ .' ~~ U.S. POSTAL SERVICE CERTIFICATE OF MAILING ..... , '"' ~~ ~ ~ -:::;j~:g' NOcn--o . .w~O~ ",. -< '" " i!\ '" '" One piece of ordinary mail addressed to' PillO!)... C,Qin \ ~, \l)Q\nut Bottom !Zoo.a ~UlSb"~, ~l'l \1~51 PS Form 3817 I January 2001 U.S. POSTAL SERVICE CERTIFICATE OF MAILING =-6~~~~~ fN~~~~~!~~~~~~~NATIONAl MAIL, DOES NOT Received From." 07BnftllBar;~,*,Sch~tr..~ ,~, J9 l\3f-~ &u+Y1 Street' ,'. /< ~ ~. )'. f, ffi 13 .... '"""'......~ i" , One piece of ordinary meil addressed to:" g.' ~bnn CA'I,,' . ~ "'" ..:M:ll Li nCilln \A)4Jl tas t i)f _F~ltt.~il\t;) \..JI'A 110\~~ '" '" '" '" UIJ :~ ~~ ~2 '" n c: ~ ~ . i -;"~'!' ~N~cn_"l:I -f' .w~~ Q. -< en ~ ~ '" PS Form 3817, January 2001 EXHIBIT "B" . II CERTIFICATE OF SERVICE I hereby certify that on May rl, 2006, I, David A. Baric, 1SqUire, of O'Brien, Baric & Scherer did serve a copy of the Praecipe To Enter Default Judgment ~ursuant To Pa.R.C,P, 1037, by first class U.S, mail, postage prepaid, to the parties listed below, a~ follows: John Cain 7411 Lincoln Way East Fayetteville, Pennsylvania 17222 Diana Cain 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257 David A. aric, Esquire 0 .-0 ~ oC~ ~.,. ~; c.:::'> <T' \~ ~ ("-. I,;' > :f-n ~ '. );:IP -< rY\ r-: ~, " '" ""CJfT1 ~ ~ I'V 'Oy ~. 2)9, ~ p C> -'," \ - ~ 25ff. -.l 9 \ - * :"A ~ <> ~ \, 0 "'" ~ 0 ~ \ _...'" <,Jl b;:1 - ~. ..... (' .... .-- II SHlPPENSBURGI SOUTHAMPTON MANOR, L.P" Plaintiff v, DIANA CAIN and JOHN CAIN Defendants , i I \ IN THE COURT OF CbMMON PLEAS OF CUMBERLAND CO~TY, PENNSYLVANIA NO, 2006-2048 CNIL tERM CIVIL ACTION-LAW NOTICE OF JUDGMENT PURSUANT TO Pa. C.P.236 TO: John Cain 7411 Lincoln Way East Fayetteville, Pennsylvania 17222 Notice is hereby given to you of entry of a judgment against y u in the above matter. Date: ~1!f10~ (') c-> ~ = ;:: = "'"' :l!: :1 ,,~ n~ -< t-: N --n,m ;:pC( ,t:- :2,0 :P" :'J; ~~~ c.J~- :;!: _>",,0 - orTI - -t ;; c> '-< II SHIPPENSBURGI SOUTHAMPTON MANOR, L,P" Plaintiff v, DIANA CAIN and JOHN CAIN Defendants IN THE COURT OF dOMMON PLEAS OF CUMBERLAND COtjNTY, PENNSYLVANIA NO, 2006-2048 CNILITERM , , CIVIL ACTION-LA Wi NOTICE OF JUDGMENT PURSUANT TO Pa RC.P. 236 TO: Diana Cain 121 Walnut Bottom Road Shippensburg, Pennsylvania 17257 Notice is hereby given to you of entry of a judgment against ou in the above matter, Date: 41P/A( (') ~, ';:::5 "'"-" <C>' :% ".,. _c N x:- ~ ~ - - ~ .-\ -C:-n f1ip -011"1 :fJt;:' -:")() -'.::i.\", ~,~~l <c){ \ 1 :~ "?'" ~~ - o SHERIFF'S RETURN - OUT OF COUNTY ., . CASE NO: 2006-02048 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHIPPENSBURG/SOUTHAMPTON MANOR VS CAIN DIANA ET AL R, Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: CAIN JOHN but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of FRANKLIN County, Pennsylvania, to serve the within COMPLAINT & NOTICE On May 5th , 2006 , this office was in receipt of the attached return from FRANKLIN Sworn and 6.00 9.00 10.00 33.00 .78 58.78 05/05/2006 OBRIEN BARIC SCHERER CL 4~:>./OL subscribed to b~fore me ~k~~ R. Thomas Kline Sheriff of Cumberland County Sheriff's Costs: Docketing Out of County Surcharge Postage this day of A.D. Prothonotary In The Court of Common Pleas of Cumberland Couuty, Pennsylvania . Shippensburg Southampton Manor LP vs. Diana Cain et al SERVE: Jam cain No. 06-2048 civil Now, April 12. 2006 , I, SHERIFF OF CUMBERLAND COUNTY, P A, do hereby deputize the Sheriff of Franklin County to execute this Writ, this deputation being made at the request and risk of the Plaintiff. .. r~~<:~ Sheriff of Cumberland County, PA Affidavit of Service Now, , 20~ at g:30 o'clock If- M. served the within , A,...4- rJLv;j ~~ at !~ u--. I 17::101 by handing to a ~tf- ~ and made mown to /1 .. ) , copy of the original (!A-l"1't.I>..h... 'r ~ Q . /J-~ the contents thereof, . ., ~'1-,lJA:. . ~'t~: Sworn and subscribed before A I. . me this 3- day of /J1I1P ,20!.tL k~.~~ .. ~=a~a! <. COSTS SERVICE MILEAGE AFFIDAVIT $ $ 33~ SHERIFF'S RETURN - REGULAR . CASE NO: 2006-02048 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND SHIPPENSBURG/SOUTHAMPTON MANOR VS CAIN DIANA ET AL MARK CONKLIN , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon CAIN DIANA the DEFENDANT , at 0845:00 HOURS, on the 13th day of April , 2006 at SHIPPENSBURG HEALTH CARE CENTR 121 WALNUT BOTTOM ROAD SHIPPENSBURG, PA 17257 by handing to HEATHER FAUST, RECEPTIONIST, ADULT IN CHARGE a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff's Costs: Docketing Service Affidavit Surcharge So Answers: Sworn and 18.00 16.72 .00 10.00 .00 44.72 ~ s(.u(vt. Subscribed to before r~~/~~ R. Thomas Kline 05/05/2006 OBRIEN BARIC By: me this day of A.D. Prothonotary I !I~ i il SHIPPENSBURGI SOUTHAMPTON MANOR, L.P., Plaintiff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA v. NO. 2006-2048 CIVIL TERM DIANA CAIN and JOHN CAIN CIVIL ACTION-LAW Defendants PRAECIPE TO SATISFY TO THE PROTHONOTARY: Please mark the judgment entered in this matter on May 24, 2006 has having been satisfied and discontinued. Respectfully submitted, David A. Baric, Esquire J.D. 44853 19 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 dab.dir/shcc/cain/satisfy. pra t !.... \1 CERTIFICATE OF SERVICE I hereby certify that on September 26,2006, I, David A. Baric, Esquire of O'Brien, Baric & Scherer, did serve a copy ofthe Praecipe To Satisfy, by first class U.S. mail, postage prepaid, to the parties listed below, as follows: John Cain 7411 Lincoln Way East Fayetteville, Pennsylvania 17222 Diana Cain 121 Walnut Bottom Road Shippensburg, Pennsylvania 17201 David A. Baric, Esquire r--.:> = = 0" (./) f'T1 V N 0'" -0 :r.: w c...n 0:> o -n ........ :J::n rn, "m :JJ CJ C) (1. :.:.! -T;~ ;25 /) in ~ ....j.::O- "'.0 ~