HomeMy WebLinkAbout06-3464
POST & SCHELL, P.C.
BY: PAULA J. MCDERMOTT
I.D. #:46664
12 NORTH SECOND ST., 12TH FLOOR
HARRISBURG, PA 17101-1601
(717) 731-1970
PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE
Plaintiff,
v
JOAN SACHS, Individually and as Power of
Attorney for Luther Sachs,
Defendant.
ATTORNEYS FOR PLAINTIFF
PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
CIVIL ACTION - LAW
NOTICE TO DEFEND
You have been sued in court. If you wish to defend against the claims set forth in the
following pages, you must take action within twenty (20) days after this complaint and notice are
served, by entering a written appearance personally or by attorney and filing in writing with the
court your defenses or objections to the claims set forth against you. You are warned that if you
fail to do so the case may proceed without you and a judgment may be entered against you by the
court without further notice for any money claimed in the complaint or for any other claim or
relief' requested by the plaintiff. You may lose money or property or other rights important to
you.
YOU SHOULD "FAKE 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 FOR'l H 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
AVISO
Le han demandado a usted en la cone. Si usted quiere defen-derse de estas demandas
expuestas en las paginas siguien-tes, usted tiene veinte dial de plazo al partir de la fecha de la
demanda y la notitica-cion. Hace falta ascentar una comparencia escrita o en persona o con un
abogado y entregar a la torte en forma escrita sus defensas o sus objeciones a las demandas en
contra de su persona. Sea avisado que si usted no se defiende, la cone tomara medidas y puede
continuar la demanda en contra suya sin previo aviso o notification. Ademas, la torte puede
decidir a favor del deman-dante y requiere que usted cumpla con todas las provisio-nes de esta
deman-da. Usted puede perder dinero o sus propieda-des u otros derechos importan-tes para
usted.
LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATA-MENTE, SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFICIENTE DE PAGAR TAL SERVICIO,
VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE
ENCUENTRA F,SCRITA ABAJO PARA A VERIGUAR DONDE SE PUEDE CONSEGUIR
ASISTENCIA LEGAL.
CUMBERLAND COUNTY BAR ASSOCIATION
32 S. Bedford Street
Carlisle, PA 17013
(717) 249-3166
800-990-9108
2
POST & SCHELL, P.C.
BY: PAULA J. MCDERMOTT
I.D. #:46664
17 NORTH SECOND STREET
12TH FLOOR
HARRISBURG, PA 17101-1601
717-731-1970
PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE
ATTORNEYS FOR PLAINTIFF
PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
Plaintiff,
V.
JOAN SACHS, Individually and as Power-of-
Attorney for Luther Sachs,
CIVIL ACTION - LAW
NO: Ole- 3Y`q 1:4.,U?
Defendant.
COMPLAINT
AND NOW, comes Plaintiff, Presbyterian Homes, Inc. (hereinafter "PHI"), by and
through its attorneys, Post & Schell, P.C., and in support of this Complaint avers the following:
Plaintiff PHI is a Pennsylvania non-profit corporation with an address of 1217
Slate Hill Road, Camp Hill, Cumberland County, PA 17011.
2. Plaintiff operates a facility at Green Ridge Village, 210 Big Spring Road,
Newville, Cumberland County, PA 17241-9486.
3. Defendant Joan Sachs is an adult individual and Power of Attorney for her
husband, Luther Sachs.
4. Luther 1. Sachs has been a private pay resident of Plaintiffs facility at Green
Ridge Village since April 18, 2005.
5. On April 18, 2005, Defendant signed an Admission Agreement as Power of
Attorney for her husband and agreed to pay out of his funds all charges incurred in providing his
care at the facility.
6. A true and correct copy of the Admission Agreement is incorporated hereby and
attached hereto as Exhibit "A."
7. Mrs. Sachs also signed a Guarantor Agreement which obligated her to make
payments to PHI from the funds of Luther t. Sachs and assist with making other payment
arrangements when personal funds were no longer available.
8. A true and correct copy of the Financial Guarantor Agreement obligating Mrs.
Sachs as indicated above is incorporated hereby and attached hereto as Exhibit "B."
9. Mr. Sachs is a private pay resident and will remain so as medical assistance has
made the determination that he is over resourced.
10. Resident Luther Sachs is in need of nursing home care because of his numerous
physical and mental impairments.
11. Defendant Joan Sachs has refused to pay for her husband's medical care and has
sequestered his assets for her own use and benefits.
12. Mr. Sachs has a veterans' pension; a pension from the Public School Employees'
Retirement System; and social security income. This income is not being remitted to Plaintiff.
13. At the present time, an amount of $40,212.99 is due and owing, which amount
will continue to rise on a monthly basis as amounts due and owing are not paid.
COUNT I - DOCTRINE OF MEDICAL NECESSARIES
14. The averments of Paragraphs 1-13 are incorporated hereby as if set forth fully and
at length.
15. Defendant Joan Sachs as the spouse of Luther Sachs has a legal obligation to pay
for the medical care provided to her invalid husband by Plaintiff.
16. Joan Sachs has refused to do so.
17. Plaintiff has been damaged by John Sachs' failure to pay in an amount of
$40,212.99.
WHEREFORE, Plaintiff respectfully requests this Honorable Court to grant judgment in
its favor and against Defendant in the amount of $40,212.99, plus monthly charges as they
accrue, with interest, costs and whatever other relief the Court may consider just and equitable.
1)
COUNT 11- BREACH OF CONTRACT
PLAINTIFF v. JOAN SACHS
18. Paragraphs 1-17 are incorporated hereby as if set forth fully and at length.
19. Defendant Joan Sachs signed a contract obligating herself to pay her husband's
assets to Plaintiff to pay for his care at Plaintiff's facility.
20. Defendant Joan Sachs has breached that contract.
21. Plaintiff has been damaged by the breach of contract in an amount of $40,212.99.
WHEREFORE, Plaintiff respectfully requests this Honorable Court to grant judgment in
its favor and against Defendant Sachs in an amount of $40,212.99, plus monthly charges for the
care of Luther Sachs as they accrue, with interest, costs and whatever other relief the Court may
consider just and equitable.
Respectfully submitted,
POST & SCHELL, P.C.
PAULA J. McDERMOTT, ESQUIRE
Attorney I.D. # 46664
17 North Second Street
12'h Floor
Harrisburg, PA 17101-1601
717.612.6012
Dated: Junel!5 , 2006 Attorneys for Plaintiff
VERIFICATION
I, Jeffrey Davis, a duly authorized representative of Presbyterian Homes, Inc., Plaintiff,
hereby swear and affirm that the facts and matters set forth in the foregoing Complaint are true
and correct to the best of my knowledge, information, and belief. The undersigned understands
that the statements made therein are made subject to the penalties of 18 Pa. C.S. §4904 relating
to unworn falsification to authorities.
PRESBYTERIAN HOMES, INC.
i
Jeffrey Chi ncial Officer
Presbyteri Home , Inc.
Date: Jane 7 2006
4
LONG TERM CARE ADMISSION AGREEMENT
1. INTRODUCTION
This Agreement is between /v v` ,t. k y' _7:r- 5?4C$b S ,
Resident, or J Q 0..w 5/$ QI) S Resident's Representative (referred to as Resident
in the Agreement) and 3a.? W'1 Health Center, a licensed Long
Term Care Facility (referred to as Health Center in this Agreement), for admission of Resident to
the Health Center on le 20 t? S._(Date)
Resident requests occupancy of Room /P? R_, a room for occupancy of P-
residents at a Daily Rate of Ste. Resident may request a room change and the Health
Center will make every effort to honor such requests as soon as possible. However, a room
change may result in a change in the Daily Rate upon occupancy of the new room. In the event
of an increase in the Daily Rate, the Health Center will provide thirty (30) days' notice of any
change, thereby giving Resident sufficient time to request a room change (for example from a
private to a semi-private room) or to transfer to another nursing facility.
The Health Center agrees to accept payments from Medicare and other contracted third
party payers for Resident's stay if Resident meets all qualifications required by Medicare or other
third party payer. Resident agrees to pay daily co-payment and/or deductibles as designated by
Medicare or other third party payers.
If Resident qualifies for Medical Assistance ("MA'), the Health Center agrees to accept
the Patient Pay Liability (as defined below) as determined by the County Assistance Office with
the balance of the payment for covered services coming from the MA Program.
II. DEFINITIONS
A. Daily Rate. The rate the Health Center charges a private pay resident for room
and board, general nursing care, housekeeping services, linen services, nutrition
management, limited in-room storage of Resident's personal belongs, and
recreational programs for each day a Resident is at the Health Center. Physician
services are not included in the Daily Rate.
B. Healthcare Surrogate. An adult who is appointed to make healthcare decisions
for Resident when Resident becomes unable to make them for himtherself.
C. Medical Director. The physician designated by the Health Center to be
responsible for resident care policies and the coordination of medical care in the
Health Center.
D. Clinical Records. All records (excluding financial records) pertaining to a
particular Resident that are prepared and maintained by Health Center.
E. Patient Pay Liability. The amount of personal funds, as determined by the
Commonwealth County Assistance Office, that a Resident who is receiving MA
must pay monthly to the Health Center in addition to the payment from the MA
program.
F. Personal Needs Services. Personal services such as telephone service, laundry,
beauty and hair care (exclusive of routine assistance with grooming), and
newspaper delivery provided by the Health Center to Residents for their
convenience at Residents' expense.
G. Private Pay Resident. A Resident who pays the Daily Rate and all other fees of
the Health Center from his/her own resources (including private insurance and
Medicare Part B) and who is not covered by or has exhausted Medicare Part A
and MA coverage.
H. Resident Funds. Personal funds of a Resident that the Resident has authorized in
writing that the Health Center shall manage for the Resident.
1. Resident's Representative. A person who is responsible for making decisions on
behalf of the Resident and has been so designated in writing by the Resident or a
court of competent jurisdiction. If a Guarantor Agreement is attached to this
Agreement, the Resident's Representative is only obligated to make payment
from the Resident's personal funds. Reference in this Agreement to Resident
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shall also include, as appropriate, the Resident's Representative or other person
authorized to act on Resident's behalf.
J. Skilled Nursing Care. Professionally supervised nursing care and related medical
and other health services provided to an individual not in need of hospitalization,
but whose needs are above the level of room and board and can only be met in a
long-term care nursing facility on an inpatient basis because of age, illness,
disease, injury, convalescence or physical or mental infirmity.
K. Specialty Care Services. Medical services ordered by a physician for a Resident
that are not included in the Daily Rate. Medicare and Medicaid each include
certain Specialty Care Services in the per diem rates, but neither include all such
services.
L. Transfer and discharge. Movement of a resident to a bed outside of the certified
facility or unit whether that bed is in the same physical plant or not. Transfer and
discharge do not refer to movement of a resident within the same certified facility.
III. HEALTH CENTER OBLIGATIONS:
The Health Center will:
A. provide, as part of the Daily Rate, room and board, general nursing care,
housekeeping services, linen services, nutrition management, limited in-room
storage of Resident's personal belongings, and recreational programs. General
nursing care does not include private duty nursing.
B. provide Specialty Care Services ordered by Resident's treating or attending
physician. Although additional fees for specialty services may be covered by
third party payers, the Specialty Care Services identified on Exhibit A are not
included in the daily rate, and are billed at the rates set forth in Exhibit A. Any
items ordered by a physician, which are not identified on the Exhibit A will be
provided at charges identified by the Health Center prior to the delivery of the
service.
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C. provide Personal Needs Services, at Resident's expense (at the rates set forth on
the Fee Schedule attached as Exhibit A) and at Resident's request, including but
not limited to:
1. Beauty/Barber Services
2. Newspaper delivery and personal reading materials
3. Local and Long Distance Telephone Services
4. Cable Services, depending on cable provider
5. Personal laundry, dry cleaning and mending
6. Personal clothing.
D. provide safekeeping of Resident Funds, if authorized in writing by the Resident,
and make those funds available, at Resident's request, during normal business
hours.
1. Resident may manage his/her financial resources if (s)he wishes.
2. Residents may keep a limited amount of funds at the Health Center, the
maximum amount, which is specified from time to time by the Health
Center.
3. Requests for withdrawals in excess of $50.00 require advance notice to
assure availability of cash at the Health Center. Resident Funds shall be
retained in compliance with State and Federal regulations. Resident Funds
exceeding $50.00 shall be placed in an interest bearing account. A written
quarterly statement of these funds shall be provided to Resident. Resident
agrees to return signed copy to facility if required.
E. provide refunds of unused advance payments and Resident Funds within thirty
(30) days after deductions for payment of any outstanding bills or other amounts
due the Health Center after Resident's discharge or death. In the event of
Resident's death, refunds will be made to the authorized representative of
Resident's estate.
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Admlubn AWPA/MA 104M
F. assist Resident in applying for and obtaining private insurance and/or public
benefits to cover the cost of the Resident's care.
G. transfer or discharge Resident out of the Medicare or Medicaid certified portion of
the Health Center only for medical reasons, for Resident's welfare, because the
safety or health of individuals in the Health Center is endangered, because the
Resident has failed, after reasonable notice, to pay for a stay at the Health Center,
or with the voluntary consent of Resident. Except in emergency situations, at
least thirty (30) days' notice will be provided to Resident and Resident's
Representative to assure that the transfer is safe and orderly. The Health Center
reserves the right and discretion to move Resident to another room or bed within
certified parts of the Health Center consistent with the safety, care and welfare
needs of the Resident.
H. arrange for Resident's transfer or discharge upon the order of Resident's personal
physician when he/she deems it necessary to receive services the Health Center is
not qualified to provide or at Resident's request.
1. honor Resident's Rights as outlined in the Department of Public Welfare
Admissions Notice Packet (MA 401).
J. hold Resident responsible to pay for any damages or injuries caused by Resident
to other persons, residents or stafE Resident shall indemnify and hold the Health
Center harmless from any claims, actions or proceedings against the Health
Center resulting from Resident's actions or omissions. Health Center will be
responsible for loss of or damage to Resident's personal property by Health
Center staff.
K. provide Resident with a locked drawer or box for Resident's valuables or for
medications retained for self-administration. Resident may self-administer
medications only in certain circumstances and may not have medications in
his/her room without physician authorization.
L. provide Resident with a choice of pharmacy if Resident does not wish to utilize
the pharmacy provider designated by the Health Center. With this choice,
pharmacy must provide medications in compliance with all applicable laws and
under a delivery system that is consistent with the one used by the Health Center,
must provide a monthly written profile of all drugs provided to the Health
Center's consultant pharmacist, and must be delivered from the provider
pharmacy in tamper-proof containers, directly to the Health Center's licensed
nursing staff.
M. provide Resident with a choice of attending physician who will provide medical
care during the Resident's stay at the Health Center and who shall comply with
the Health Center's rules, regulations, policies and procedures and all applicable
laws and credendalling standards. Resident may also designate an alternate
attending physician in the event that the primary attending physician is
unavailable. In the event that Resident's attending physician(s) are unavailable,
the Resident authorizes Health Center's Medical Director or other physician
designated by the Health Center to issue appropriate orders.
IV. RESIDENT OBLIGATIONS
The Resident agrees to:
A. by signing this Agreement, Resident certifies that (s)he is competent, and has
never been adjudged incompetent, and is entering into this Agreement of his/her
own free will.
1. In the event Resident has been adjudged incompetent, Resident's
healthcare surrogate will attest, in a separate document that (s)he has the
legal authority to act on behalf of the Resident.
B. provide the Health Center with all information about Resident's health status and
financial resources. Failure to accurately identify Tmomrces and income, or the
submission of false information may amount to a violation of law and may result
in the termination of this Agreement by and at the option of the Health Center.
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C. provide the Health Center with a copy of all current insurance cards. Resident
will provide the Health Center with changes in insurance coverage or financial
status in a timely manner, and will update the information provided to the Health
Center from time to time, as requested. Resident understands that malting
incomplete or inaccurate disclosures will be considered a breach of this
Agreement.
D. authorize the Health Center to provide care and treatment to Resident consistent
with the terms of this Agreement and to carry out the orders of the Resident's
treating or attending physician or of the physician designated by the Health
Center. Resident also authorizes the Health Center to obtain all necessary clinical
and/or financial information from the hospital or nursing facility from which
Resident may be transferring.
E. authorize the Health Center to make Resident's Clinical Records available to
Health Center staff and agents. Resident also authorizes the release of the
Resident's Clinical Records to any other health care provider from whom
Resident receives treatment, to third-party, payors of health services, and to any
managed care organization (MCO) in which Resident may be enrolled. Resident
also authorizes the release to the Health Center of records prepared and
maintained by any third-party payor of health care services pertaining to health
care services rendered to the Resident by the Health Center. Resident also
acknowledges receipt of the "Release for Electronic Transmission of Minimum
Data Set" ("MDS'J, which explains the MDS system of records using Resident
data. Resident's Clinical Records will remain otherwise confidential, and shall
not be made available to anyone other than Resident or authorized agents of the
state or federal governments without the express written authorization of Resident
or without a subpoena or other judicial order.
F. cooperate fully with the Health Center and any third party payer to secure
payment. Resident authorizes the Health Center to collect any payments made by
third parties on Resident's behalf directly from the third party payer. Resident
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also authorizes the Health Center to make claims, file appeals or grievances, and
take other actions necessary and appropriate to secure receipt of third-party
payments to reimburse the Health Center for its charges for the stay and care of
Resident to the fullest extent permitted by law. Provided that Resident may, but
shall not be required to authorize the Health Center to pursue grievances or
appeals on Resident's behalf under, Pennsylvania's Quality Health Care
Accountability and Protection Act, to the fullest extent permitted by law and as
security for payment of the Health Center's charges, Resident hereby assigns to
the Health Center all of Resident's rights to any third-party payments now or
subsequently payable for services rendered by or provided under arrangement
through the Health Center.
0. pay the Daily Rate established for the accommodation requested. Payment is due
30 days in advance, and Resident agrees to make full payment by the first of each
month. Collection procedures are initiated after thirty (30) days of unpaid
balances. Interest shall be charged on unpaid balances.
1. If the Health Center initiates any legal actions to collect payments due
from Resident under this Agreement, Resident shall be responsible to pay
all attorney's fees and costs incurred by the Health Center in enforcing
Resident's financial obligations under the Agreement.
2. This Agreement shall serve as an assignment to the Health Center of as
much of Resident's property as equals the amount of any unpaid
obligations under this Agreement, and this assignment shall be an
obligation of Resident's estate that may be enforced against Resident's
estate. Resident's estate shall be liable to and shall pay to the Health
Center an amount equivalent to any unpaid obligations of Resident under
this Agreement. This liability shall apply whether or not Resident is
occupying the Health Center at the time of Resident's death.
H. pay for additional items, services and equipment not included in the Daily Rate as
identified by the Fee Schedules, attached as Exhibit A.
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I. understand that Resident will be notified thirty (30) days in advance of changes in
the Daily Rate except when Resident requests room change, changes in charges
for Specialty Care Services or Personal Needs Services, or changes in billing
procedures, and agree that the changes will be effective upon the date designated
by the Health Center.
J. understand that the Resident may continue to live at the Health Center as long as
Resident continues to pay the Daily Rate. Resident may be discharged for non-
payment of incurred charges or transferred for the benefit of the Resident or
others, as set forth in Section M(H) of this Agreement.
K. acknowledge that non-payment of the Daily Rate for a private room will result in
a room change.
L. acknowledge that the Health Center has the discretion, with thirty (30) days'
notice, to transfer Resident to another room or bed within the Health Center
consistent with the safety, care and welfare needs of Resident. The Health Center
also has the discretion, upon thirty (30) days' advance notice, to transfer or
change Resident's roommate, if any, at any time consistent with the needs of the
Health Center.
M. terminate this Agreement upon written notice to the Health Center, but if Resident
leaves for any reason other than a medical emergency or death, Resident must
give reasonable advance written notice to the Health Center.
N. notify the Health Center at least two months before the Resident has insufficient
resources, funds or income to meet his/her financial obligations and to apply for
MA benefits timely. If Resident is no longer able to pay the Daily Rate and is not
eligible for MA, Resident agrees to vacate the Health Center.
0. pay co-payments and/or deductibles for services covered by the Medicare
Program or other third party payer, and pay the Health Center within thirty (30)
days of receipt of services for those services not covered by the Medicare
Program or other third party payer.
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P. pay for items and services requested by Resident and not covered by MA within
thirty days of receiving the non-covered service.
Q. pay for any damages or injuries caused by Resident to other persons, residents or
staff, and indemnify and hold the Health Center harmless from any claims, actions
or proceedings against the Health Center resulting from Resident's actions.
R. comply with reasonable rules, regulations, policies and procedures that the Health
Center establishes from time to time and makes available to Residents, subject to
reasonable accommodation of Resident's individual needs and preferences. The
Health Center's rules, regulations, policies and procedures are for purposes of
internal management and shall not be construed as imposing contractual
obligations on the Health Center and are subject to change from time to time.
S. acknowledge receipt of the Resident Handbook, a document that provides
Residents with Health Center rules, regulations, policies and procedures.
T. acknowledge receipt of information on Advance Directives in the absence of
providing the Health Center with an existing Advance Directive or Living Will.
U. provide the Health Center with a copy of any and all Durable Powers of Attorney,
Guardianships, and/or Advance Directives pertaining to the Resident.
V. acknowledge that (s)he has read and understands the terns of this Agreement, that
the terms have been explained to them by a representative of the Health Center,
and that (s)he has had an opportunity to ask questions about the Agreement.
V. MEDICARE AND MEDICAID
The Health Center is certified to participate in the Medicare and Medicaid Programs.
The Health Center's participation in these programs is subject to termination by either the Health
Center or the responsible government entity. The Pennsylvania Department of Public Welfare
(DPW) is responsible for administering benefits under the Medicaid Program and the Centers for
Medicare and Medicaid Services (CMS) is responsible for administering the Medicare program
through an intermediary. The Resident acknowledges that the Health Center is not responsible
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for and has made no representations regarding the actions or decisions of DPW, CMS or the
Medicare intermediary in administering these programs.
A. Medicare
If Resident is eligible for benefits under the Medicare Program, Resident understands that
certain skilled nursing and related health care services may be covered by Medicare. The Health
Center will bill Medicare Part A on behalf of the Resident for slilled nursing services and
payment will be made by Medicare Part A directly to the Health Center for services received by
Resident. When the Health Center notifies Resident that the nursing services being provided to
the Resident no longer qualify as a sldlled service, the Resident may request that the Health
Center bill Medicare anyway. If Medicare denies coverage, Resident agrees to be responsible for
the charges incurred on the Medicare Part A non-covered days.
The following describes coverage under the Medicare Part A Program:
1. Medicare Part A covers from one (1) to one hundred (100) days at the
Health Center. Coverage is not guaranteed and is limited to the unused
days in the Resident's benefit period Conditions stipulated by Medicare
must be met for coverage to begin and remain in force.
2. The Medicare Part A Program pays for all covered charges from day one
(1) through day twenty (20) if the criteria for skilled service is met.
3. The Medicare Part A Program pays a portion but not all of the charges
from day twenty-one (21) through day one hundred (100). The Resident is
responsible for and shall pay any co-insurance or deductible amounts as
determined by the Medicare Part A program. Depending on the
circumstances, this payment may be made by personal health insurance,
MA, or personal,funds.
4. The Medicare Part A Program covers the following services: room and
board, linens, meals, most prescription medications, therapy services, most
medical supplies, non-private duty nursing services, most recreational
services, most social services, and most personal hygiene items provided
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by the Facility. (Note: only the type and brand of personal hygiene items
provided by the Health Center are included.)
5. Some items and services not covered by the Medicare Part A Program
include, but are not limited to: personal clothing, eyeglasses, hearing aids,
services of a beautician or barber, guest meals, special or alternative meals
not required for therapeutic purposes or as a nutritional substitute, services
not deemed medically necessary, and personal telephone service. The Fee
Schedule for items and services provided to Medicare Part A eligible
Residents that are not covered by Medicare Part A is attached as Exhibit
A.
6. Bed hold days are not covered by the Medicare Pat A Program (See
Section VII.)
7. Residents covered by Medicare Part A should not go out on overnight
leave as this may disqualify them from farther coverage by Medicare Part
A.
8. Residents may be covered for therapy and other ancillary services under
the Medicare Part B Program. The Health Center or provider approved by
Health Center will bill Medicare Part B directly for these services. The
Residents are responsible for the annual deductible and the co-insurance
payment for Medicare Part B covered services.
9. Resident is responsible to pay the Health Center for services and supplies
not covered by the Medicare Program
10. In the event that Medicare coverage is changed by law, those changes will
control and take precedence over any contrary provision in this
Agreement.
B. Medicare Manaeed Care
The Health Center participates as a provider of skilled nursing services under some, but
not all Medicare MCOs.
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1. Requirements for eligibility for Medicare payments, deductibles and co-
insurance may be different from those discussed in Section V(A). Pre-
authorization of services is required by Medicare MCOs, and if the
Resident chooses to have services which the MCO refuses to pre-
authorize, Resident shall pay the Health Center for those services. If the
MCO refuses coverage on the grounds that it does not consider an item or
service to be medically necessary, Health Center or MCO will provide an
Advance Beneficiary Notice of that determination. The Health Center will
communicate directly with Resident's Medicare MCO to obtain
authorization for continued Medicare managed care coverage.
2. The Health Center will accept payment from the Medicare MCO as
payment in full only for those services and supplies covered by the
Medicare MCO. Resident is responsible for any copayments or other
costs assigned to Resident or not covered by the MCO under the specific
terms of the managed care plan.
3. Resident acknowledges that an MCO for which the Health Center is not an
authorized provider may not approve payment for services provided by the
Health Center, so that Resident may be required to pay the Health Center
directly. Resident also acknowledges that the Health Center is not
responsible for and has made no representations regarding the actions or
decisions of any MCO for which the Health Center is an authorized
provider, including decisions relating to a denial of coverage or refusal to
pay on behalf of the Resident.
4. The Health Center reserves the right to stop its participation in any MCO
at any time and in its sole discretion. To the extent practicable, the Health
Center will provide advance notice to Residents enrolled in a particular
managed care plan or insurance program of its decision to stop
participation in that managed care plan or insurance program
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j I
C. Medical Assistance Proeram
1. Residents who qualify for coverage under the MA Program must apply for
and be approved for these services at the County Assistance Office. It is
Resident's responsibility to pursue MA coverage. Until approval of MA
coverage is obtained, the Health Center will consider Resident to be a
Private Pay Resident.
2. Resident will be required to use the Patient Pay Liability to pay the Health
Center for the Resident's stay in conjunction with the MA Program.
Periodic adjustments in the Patient Pay Liability are made by the County
Assistance Office and when issued, will supersede all previous
determinations. Resident shall arrange, if possible, for the designation of
the Health Center for direct deposit of any Social Security or related
benefits or any other income sources of the Resident in an amount not to
exceed the Patient Pay Liability.
3. MA program coverage includes the following: room and board,
prescription and non-prescription medications, meals, linen service,
nursing services, incontinence care, social services, recreational activities,
personal laundry, a hair out every six (6) weeks, a shampoo and set every
two (2) weeks, one permanent per year, and personal hygiene items
provided by the Health Center. (Note that only the type and brand of
personal hygiene items provided by the Health Center are included) The
MA Program limits the frequency of coverage for the purchase of
eyeglasses, hearing aids, and dentures.
4. The Health Center will not charge, solicit, accept or receive monies from
or on behalf of Resident for bed hold days covered by MA Program,
except for the Patient Pay Liability, to cover the cost of Resident's stay or
as a condition of admitting a Resident under the MA Program.
5. Some items and services not covered by the MA Program include, but are
not limited to: personal telephone service, personal clothing, guest meals,
brand name personal hygiene items, and additional services provided by a
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Adminion AgrJFA MA 104342
-
')
beautician other than those listed above. Resident is responsible for
charges incurred for these services at the rates listed on the Fee Schedule
attached as Exhibit A in addition to the patient pay liability amount.
6. Residents receiving MA coverage are permitted to keep the amount that
has been designated as the Resident's personal needs allowance for
personal spending. Personal funds may be given to the Health Center for
safekeeping (see Health Center Obligations in Section III).
7. The MA Program provides for bed hold days for limited periods of time
during Resident's stay.
a) Up to fifteen days bed hold days are allowed when Resident is
transferred to a hospital.
b) Up to thirty days bed hold days are allowed annually for
intermittent therapeutic leave from the Health Center.
C) The bed hold days referenced above are based upon the law in
effect at this time, and may be subject to change if the governing
state law is changed.
8. The Health Center provides equal access to its services to all individuals,
regardless of payor source.
VI. THIRD-PARTY PAYMENTS
A. If Resident is or becomes eligible to receive financial assistance or reimbursement
from any third parties (such as private insurance, employee benefit plans, MA,
Medicare, managed care coverage, supplemental medical or other health
insurance, supplemental security income insurance, or old-age survivors' or
disability insurance), the Health Center reserves the right to collect such payments
directly from the third-party. Resident shall cooperate fully with the Health
Center and each third-party payor to secure payment, and Resident shall designate
the Health Center, to the extent permitted by law, as the recipient of direct deposit
for receipt of Federal Social Security benefits or any other Federal or State
government assistance, reimbursement, or benefits to the extent of all amounts
due the Health Center.
-15-
Admi"n AsOPANMA 1040-C
}
B. Resident authorizes the Health Center to make claims and to take necessary
actions to secure receipt of third-party payments to reimburse the Health Center
for its charges for the stay and cam of Resident. To the fullest extent permitted by
law, as security for payment of the Health Center's charges, Resident agrees to
assign to the Health Center Resident's rights to any third-party payments now or
subsequently payable to satisfy all charges due under this Agreement. Resident
shall endorse and turn over to the Health Center any payments received from
third-party payor to the extent necessary to satisfy the charges under this
Agreement.
C. In the event of any denial of coverage by the Resident's insurance company,
Resident shall pay the facility for all non-covered services retroactive to the date
of the initial delivery of services.
VII. READMISSION - BED HOLD POLICY
A. A Health Center representative shall communicate with Resident regarding
his/her desire to continue to occupy the Health Center bed during hospitalization
or therapeutic leave. Verbal consent shall be given to the Health Center
representative who shall document this consent in the clinical record. Written
consent shall be obtained following the verbal consent. See Fee Schedule (Exhibit
A) for bed-hold rates.
B. Bed holds for Residents enrolled in the MA Program are subject to the provisions
of Section 5(C)(7).
C. Resident's belongings shall be removed from the Health Center within 24 hours if
Resident does not execute a bed hold authorization. Belongings not removed in a
timely fashion may be packed and stared.
VIII. CIVIL RIGHTS COMPLIANCE
All Presbyterian Homes, Inc. facilities, including the Health Center, are open to all in
need of services and are not restricted to members of the Presbyterian Church. The Health
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?dmissMn ??n/P?IM• 111JtlIJ1I
Center does not discriminate on the basis of race, color, national origin, age, ancestry, sex,
handicap or disability.
IX. REGULATION
The Health Center and Resident recognize that Health Center is licensed by the
Pennsylvania Department of Health and is regulated by the DPW. The Health Center and
Resident recognize that Health Center is also regulated by CMS of the United States Department
of Health and Human Services. Both parties recognize that regulatory changes may alter the
conditions of this agreement.
X. GRIEVANCE PROCEDURE
If Resident believes that Resident is being mistreated in any way or Resident's rights
have been or are being violated by staff or another resident, on in any other way, Resident may
submit a complaint to the Health Center's Director of Nursing and/or Administrator, and follow
the Health Center's grievance procedure as described in the Resident Handbook The Health
Center's grievance procedure does not preclude Residents from pursuing grievances with
appropriate regulatory agencies.
XI. ARBITRATION
Any controversy, dispute or disagreement arising out of, or relating to this Agreement, or
concerning any rights arising thereunder or the breach thereof shall be settled exclusively by
arbitration, which shall be conducted at the Health Center in accordance with the American
Health Lawyers Association Alternative Dispute Resolution Service Rules of Procedure for
Arbitration. Judgment on the award rendered by the arbitrator shall be binding on both parties
and may be entered in any court having jurisdiction thereof. Provided, however, that this
arbitration clause is not intended to limit or supersede hearing rights that are guaranteed to a
resident under the Medicare or MA programs or an applicable state law.
XII. GOVERNING LAW
This Agreement shall be governed by and construed in accordance with the laws of the
Commonwealth of Pennsylvania. The Agreement shall be binding upon and inure to the benefit
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Admisdoa AWPA/MA 1""2
r
of each of the undersigned parties and their respective heirs, personal representatives, successors
and assigns.
XIII. SEVERABILITY
The various provisions of this Agreement shall be severable one from another. If any
provision of this Agreement is found by a court or administrative body of proper jurisdiction to
be invalid, the other provisions shall remain in full force and effect as if the invalid provision had
not been a part of this Agreement.
XIV. ENTIRE AGREEMENT
This Agreement represents the entire understanding between the parties, and supersedes
all previous representations, understandings or agreements, oral or written, between the parties.
XV. MODIFICATIONS
The Health Center has the right to modify unilaterally the terms of this Agreement to the
extent necessary to conform to subsequent changes in law or regulation. To the extent
practicable, the Health Center will give Resident and Resident's Representative thirty (30) days
advance written notice of any such modifications.
XVI. WAIVER OF PROVISIONS
The Health Center Executive Director reserves the right to waive any obligation of
Resident under the provisions of this Agreement in its sole and absolute discretion. No term,
provision or obligation of this Agreement shall be deemed to have been waived by the Health
Center unless and except to the extent that such waiver is in writing by the Health Center. Any
waiver by the Health Center shall not be deemed a waiver of any other term, provision or
obligation of this Agreement, and the other obligations of Resident and this Agreement shall
remain in full force and effect.
. ig_
Admbdoe ApJPA/MA 104"2
Signatures
This Agreement and any addenda to this Agreement constitute the entire Agreement and
understanding between the Health Center and the Resident with respect to the subject matter of
this Agreement and supersede all prior Agreements and understandings. There are no
Agreements, understandings, restrictions, warranties, or representations between the Health
Center and the Resident other than those set forth in this Agreement, or incorporated in this
Agreement by reference. This Agreement may be amended only by a document in writing
signed by the Resident and the Administrator or Executive Director, and no act or omission of
any employee or agent of the Health Center shall alter, change or modify any of the provisions of
this Agreement.
L==?
Admini or Ex? vc Director Date
Resident Date
Rest Reprzsentative
Witness
Y//% ?y-
Date
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Date
-19-
Admialon ABrdPA/MA 10-9842
1
p?
FINANCIAL GUARANTOR AGREEMENT
,, Lwhur
will be firiarrciv y responsible for my personal accounts during my stay at
will not be responsible for my personal finances during my stay at
and designate
as my guarantor.
As Power of Attorney for u 5U1 c?1 3 1
agree to make payments to 1
from his/her personal funds and assist with making other payment
arrangernents when personal funds are no longer available.
Guarantor or POA Signature:
Guarantor Address
Phone Number. oQ roy (902gd Date: elo 5
Resident Signature:
Date:
I
Witness Signature:
Date:
?i
2 6=03 Rev. Original auaineas Office
-t9.
iJ t
w ??
IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY,
PENNSYLVANIA
PRESBYTERIAN HOMES, INC
GREEN RIDGE VILLAGE
Plaintiff NO. 06 3464
V.
JURY TRIAL DEMANDED
JOAN SACHS, INDIVIDUALLY AND ASSIGNED TO JUDGE
AS POWER OF ATTORNEY FOR
LUTHER SACHS
Defendant
ANSWER TO COMPLAINT
NOW COMES Defendant, Joan Sachs, by and through her counsel, Gan Law
Group and files this Answer to Complaint and states as follows:
1. In response to paragraph one of Plaintiffs complaint, defendant admits the
same.
2. In response to paragraph two of Plaintiffs complaint, Defendant admits the
same.
3. In response to paragraph three of Plaintiffs complaint, Defendant admits the
same.
4. In response to paragraph four of Plaintiffs complaint, Defendant admits the
same.
5. In response to paragraph five of plaintiff's complaint, defendant sates that she
agreed to pay for all contracted for charges, not to include over billing, double
charges and amended contractual rates that were not disclosed.
6. Defendant neither admits nor denies that this is a correct copy of the contract
and leaves Plaintiffs to their strict proofs.
In response to paragraph seven of Plaintiffs complaint, Defendant neither
admits nor denies the same and leaves Plaintiffs to their strict proofs.
8. Defendant neither admits nor denies the same and leaves Plaintiffs to their
strict proofs.
9. Defendant neither admits nor denies the same as she is without sufficient
information to form a response to this allegation.
10. In response to paragraph ten of Plaintiffs complaint, Defendant admits the
same.
11. In response to paragraph eleven of Plaintiffs complaint, Defendant denies the
same as it is untrue as plead.
12. In response to paragraph twelve of Plaintiffs complaint, Defendant denies the
same as it is untrue as plead.
13. In response to paragraph thirteen of Plaintiffs complaint, Defendant denies the
same as it is untrue as plead.
DOCTRINE OF MEDICAL NECESSARIES
14. The answers contained in paragraphs one thru thirteen are incorporated herein
as reproduced in full.
15. In response to paragraph fifteen of Plaintiffs complaint, defendant admits that
she is the wife of Luther Sachs. The Defendant denies that she has the
absolute duty to pay for all of Luther Sachs medical care.
16. In response to paragraph sixteen of Plaintiffs complaint, Defendant denies the
same as it is untrue as plead.
17. In response to paragraph seventeen of Plaintiffs complaint, defendant denies
the same as it is untrue as plead
WHEREFORE, Defendant respects that Plaintiffs complaint be
Dismissed with all costs and attorney fees to be paid by Plaintiff.
18. Paragraphs one through seventeen are repeated as if reproduced in full.
19. In response to paragraph nineteen of Plaintiffs complaint, Defendant admits
that she agreed to transfer certain of her husband's assets to the Plaintiff.
20. In response to paragraph twenty of Plaintiffs complaint, Defendant denies the
same as it is untrue as plead
21. In response to paragraph twenty one of Plaintiffs complaint, Defendant denies
the same as it is untrue as plead
WHEREFORE, Defendant respectfully requests that Plaintiffs complaint be
dismissed with all costs and attorney fees to be taxed to Plaintiff.
Respectfully Submitted,
GAN LAW GROUP
Attorney ID 68721
17 West South Street
Carlisle, PA 17013
717-241-4300
Attorneys for Defendant
Richard R. Gan, Esq.
r
-n
__-1
_...?
__ :;J
SHERIFF'S RETURN - OUT OF COUNTY
CASE NO: 2006-03464 P
COLMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
PRESBYTERIAN HOMES INC ET AL
VS
SACHS JOAN
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
SACHS JOAN
but was unable to locate Her
to wit:
in his bailiwick. He therefore
deputized the sheriff of FRANKLIN
serve the within COMPLAINT & NOTICE
County, Pennsylvania, to
On July 7th , 2006 , this office was in receipt of the
attached return from FRANKLIN
Sheriff's Costs:
Docketing 18.00
Out of County 9.00
Surcharge 10.00
Dep Franklin Co 37.05
Postage 1.74
75.79 ?
07/07/2006
POST & SCHELL
So answerer ,
R. Thomas Kline
Sheriff of Cumberland County
7/a v / 0G
Sworn and subscribe to before me
this day of
A. D.
In The Court of Common Pleas of Cumberland County, Pennsylvania
Presbyterian Hanes Inc t/d/b/a Green Ridge Village
vs.
Joan Sachs
No. 06-3464 civil
Now, June 20, 2006
hereby deputize the Sheriff of
I, SHERIFF OF CUMBERLAND COUNTY, PA, do
Franklin
County to execute this Writ, this
deputation being made at the request and risk of the Plaintiff. //.
Sheriff of Cumberland County, PA
Affidavit of Service
Now, a6 , 20o(- , at l 'off o'clock P M. served the
within
`?'?-ems
upon
A.o. 'q.
at ? ??- ? ?.!'.C.cti.?-??1??(??c.u.e, l:bt-l???Ql?4.a -?-?ct-x ? ?u--, ? 7 ?-?J r
by handing to
a copy of the original
and made known to CJ
So answers.
Sworn and subscribed before
me this (o day oK _, 20
N0? 3aM Public
Richard D. McCaRY Franklin County
Chambessbur9 Soto,
My Commission Expires Jan. 29, 2007
the contents thereof.
$
COSTS
SERVICE $
MILEAGE
AFFIDAVIT
POST & SCHELL, P.C.
BY: PAULA J. MCDERMOTT
I.D. #:46664
17 NORTH SECOND STREET
12TH FLOOR
HARRISBURG, PA 17101-1601
717-731-1970
PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE
Plaintiff,
V.
JOAN SACHS, Individually and as Power-of-
Attorney for Luther Sachs,
Defendant.
ATTORNEYS FOR PLAINTIFF
PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY,
PENNSYLVANIA
CIVIL ACTION - LAW
NO: 06-3464
PRAECIPE TO SETTLE, DISCONTINUE AND END
TO THE PROTHONOTARY:
Kindly mark this action as settled, discontinued and ended on the docket.
POST & SCHELL, P.C.
Dated: September 8, 2009
PAULA J. CDERMOTT, ESQUIRE
Attorney ID # 46664
Attorneys for Plaintiff
6551118v1
CERTIFICATE OF SERVICE
I, Paula J. McDermott, of Post & Schell, P.C., do hereby certify that on the date set forth
below, I did serve a true and correct copy of the foregoing document upon the following person
via First-Class Mail, postage pre-paid, addressed as follows:
Richard Gan, Esquire
Gan Law Offices
17 West South Street
Carlisle, PA 17013
POST & SCHELL, P.C.
Paula J. McD ott
Date: September 8, 2009
6551118v1
FILED -&RO'E
OF THE PFOT-40"SOTARY
2009 SEP -9 PM 12: 41
PENN&?t.,y'AN A