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HomeMy WebLinkAbout08-17-06 "" ~ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA ORPHANS' COURT DIVISION In Re: JOSEPH M. FELDISH SR. O.c. No.: 21-06-0411 I ; PETITION FOR RULE TO SHOW CAUSE WHY AN ACCOUNTING SHOULD NOT BE FILED AND NOW, COMES, Plaintiff, Country Meadows Associates, a Pennsylvania Organization d/b/a Country Meadows of West Shore at Trindle Corners ("Plaintiff Country Meadows"), by and through its attorneys, ScHUTJER BOGAR LLC, and files this Petition for Rule to Show Cause Why An Accounting Should Not Be Filed and, in support thereof avers the following: 1. Joseph Feldish Sr. was admitted as a resident of Country Meadows, a skilled nursing facility, on or about October 18,2004. A true and correct copy of the Resident Agreement is attached as Exhibit" A" (hereafter the" Admission Agreement"). 2. On July 5, 2006, this Honorable Court appointed Good News Consulting, Inc. as Guardian for the Estate and Person of Joseph Feldish Sr. 3. Joseph Feldish Jr., son of Joseph Feldish Sr., signed the Admission Agreement as responsible party for his father, and upon information and belief, at all times relevant up to July 5, 2006, Joseph Feldish Jr. had exercised control over his father's alleged assets and monthly income, including any social security or pension income of which Joseph Feldish Sr. was a recipient. 4. Presently, Joseph Feldish Sr.'s account with Country Meadows has an outstanding balance exceeding Thirty Three Thousand ($33,000.00) Dollars, a balance that continues to accrue because Joseph Feldish Sr. is a current resident of Country Meadows' facility. 5. Despite repeated requests, Joseph Feldish Jr. has refused to bring the above-referenced account current or to account for his father's pension and or social security income. 6. Per the Admission Agreement, at all times material hereto, Country Meadows has had an immediate right to the possession of any assets or monies of Joseph Feldish Sr. that might be sufficient to pay the aforementioned debt owed to Country Meadows. WHEREFORE, Petitioner requests that this Honorable Court issue a Citation directed to Joseph Feldish Jr. to show cause, if any there be, why an Order should not be entered requiring him to file a full and complete accounting of all transactions undertaken by him with respect to his father's assets and monthly income from October 18,2004, until July 5, 2006. Respectfully submitted, Dated: q. \S .1)(.:. /~ By: Kirk . Sohonage Attorney I.D. No. 77851 305 North Front Street, Suite 401 Harrisburg, P A 17101 (717) 909-8640 Attorney for Petitioner 2 1'\1'0 uClqu lIme SEP-t7-05 10:08 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 7175331014 T-149 P.003 P.003 F-748 ~\\.Y ME..d ~~~ .~r-..."~bO o r~', .......~.. ~ ~; , ,_.-.~ I~..'~.~ -.1\ IS\ . V" ,:!!;"II'"' ,. U' \IJf Retirem.ent Couununities fJ?!esident Agreement for Assif5ted Living ~ It is a pleasure to welcome you to the Country Meadows assisted,living community. Th~se documents are kIiown as "full disclosurear residential ag'reements. They are a good deal longer than other agreements~ because they attempt to cover a multitude of possibilities that can occur when someone resides, with us. This agreement spells out as clearly and completely as possible the responsibilities that Country Meadows will undertake when you move into a Country Meadows commumty, your rights and responsibilities as a member of the Country Meadows community~ the charges that you will receive for different types of services, and the circumstances under which your care may need to be changed in the future. We are honored that you chose Country Meadows. We look forward to serving you. This Agreement is made betvieen Country Meadows Associates (hereafter the "Community") and ~e..lcUjh (referred to singly or co1Mcti;cl.~ "Youj. GENERAL The Community is located at LJ i.Y1 E. TflhcJ/~R~rne~OA1"tc.sIoUJj J fA /70s0 . (address). You have applied for accommodations at the Community and the Community has accepted Your application. This Agreement is for accommodations and supportive services in: (check one) Basic Assisted Living l:l; Wilti::1rIl Penn (restorative assisted living) Q; Meadows (memory support, assisted living in a secure environment) ~. Basic Assisted Living, William Penn and Meadows each have, two or three levels of service to assist You by providing the services that best meet Your changing needs. These are known as ctenhanced~ service levels. B. 'n1e Communi1y is licensed by the Commonwealth of Pennsylvania, Department of Public Welfare, Division of Personal Care, as a Personal Care Home (assisted living faci1ity). This Agreement is a self-renewing month-to-month Agreement that can be terminated as provided in Section VIII. A. '.i AGREEMENTS I. ACCOMMODATIONS AND SERVICES Beginning on --19- / ~ / ~ the Community airees to provide the following accommodations and services for YouJ subject to the other terms, limitations and conditions contained in this Agreement. 1 Rx Oatp,lTime , . SEP-Z7-05 10:08 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 7175331014 1-149 P.004 P. 004 F-748 ':'-C-"'r ........ _._......._~.. A.~couunodations 1. Your Apartment. You may occupy and USe Apartment No. --10 ~ , subject to the terms oftbis Agreement. Vou are enco~ged to personalize Your Apartment by providing some or all of Your oWIi.'furnisPings. If You ~oose not to furnish Your Assisted Living Apartment, the Community will provide basic furnishings for Your Apartment. If You select an Apartment in the William Penn or Meadows Wmg, the Community will. provide basic furnishings for Your Apartment; which You are encouraged to partially personalize with Your own belongings. Exhibit "AD describes the Apartment You have selected. . 2, Common Areas. You will be provided the opporbinity to use the general- , purpose areas of the CommWlity, such as lounges, craft rooms, libraries, meeting rooms and chapel. Dining areas can be reserved to accommodate 'Your guests by giving notice at least one meal in advance of desired dining time. Guest meals will be charged as shown in Exhibit "C" to this Agreement. 3. Decoration and AlteratioDs. You are free to furnish Your Apartment as You wish, except for window treatments, provided that You comply with the safety rules of the Community. You may not make any structural or physical changes to Your Apartment, unless expressly approved in writing by the Community. Any such alterations or improvements sball become the property of the Community. You may not change any lock or add any lock or locking device to Your Apartment without the prior written consent of the Community. Any changes or modifications to Your Apartment, which require the assistance of electricians. coritractors Or ~imilftT professionals, Inust be approved in advance by the Community. 4. Parking. Parking is available if You bring Your vehicle to the Community. If You operate or park Your vehicle On the premises, You agree to park the vehicle in an approved area, maintain the vehicle in operable condition, and keep current all registrations, licenses, inspections' and insurance coverage required by law. B. Customized Services 1. Meals aud Snacks. Three nutritionally balanced meals per day are included in Your Customized Service Rate. Also available are a Dental Soft Diet (Le., food softened for dental reasons) and assistance in creating Your own selections from the Comm.unity's choices to meet YOur dietary needs. Sugar-free desserts are offered for the convenience of residents dealing with diabetes and/ or weight management. Snacks also are available to You and other Residents. You are responsible for self- managing any other dietary restrictions. 2 , Rx Oa~p/Time SEP-27-2005(TUE) 09:38 SEP-Z7-05 10:08 FROM-HOFAXZFL oJ __ __, "__' .... 7175331014 7175331014 T-149 P.005 P. 005 F-748 2. Activities. The Community will provide a program of planned activities) opportunities for Community participation, and seivices designed to meet Your physical) social and spiritual needs. . .~ 3. Trausportation. The COmmunity will assist You in making arrangements for or provide transportation to meet Your medical and dental needs within a ten (10) mile radius of the Community or other prescribed range. The Community also will provide regularly ~cheduled transportation services for use by Residents for shopping and other outings. A charge may be applicable, as provided in Exhibit ICC" whic:h lists charges for additional services..All other transportation is Your responsibility. C. Health and Personal Care Services . 1. Observation. The Community, through its staff) shall regularly observe Your health status to identify changes in Your physica1, mental, emotional and social functioning and will. help You respond to Your dietary and health needs and needs for special services. In the event of an emergency, the Community staffwill summon emergency me~ical services to assist You by calling "911,)1 or otherwise summoning medical services personnel. 2. Initial aDd Annwa Medical Evaluation and Assessment. You agree to have an initial medical evaluation by Your physician, and annually thereafter, reported on a form provided by the Community. This evaluation shall be provided to the Community for retention with Your Resident record. _ With. Your assistance, the Community staffwill prepare an initial assessment of Your needs and desires and develop Your Custo~er Service Surnmaty. Other assessments may be prepared periodically at the discretio~ of the Community such as following a hospitalization, illness or injmy. '- 3. Enhanced Services. The CountIy Meadows assessment evaluates the intensity and frequency of the services outlined in Basic Assisted Living, William PeIUl Assisted Living, and Meadows Assisted Living to determine if additional or enhanced support is required. To. meet those additional needs, the Community provides for two enhanced levels of personal care assistance, "Enhanced" and "Enhanced Plus, JI the charges for which are set forth in Exhibit "B." 4. Health Needs that the Community Cannot Meet. Should You need health services which cannot he provided in the Community, either by .Community staff or outside healthcare providers with whom You contract, the Community will assist You in finding an appropriate healthcare facility. S.Assistance with Personal Care Services. Thi-ough its staff, in the Community's most appropriate level, the Commmnt,Y will make available to You assistance with dressing. grooming. bathing. dining. medication 3 , Rx OatelTime . SEP-Z7-05 10:08 5EP-27-2005(TUE) 09:38 FROM-HOFAXZFL 7175331014 7175331014 P. 006 T-J49 P.006/045 F-748 management and other activities of daily living. The Community is unable to assist You in financial management other than by cashing small personal checks amol.U'lting to $50.00 or less. ~ 6. Assistance with Ordering, Storing and Taking Medications. AJ,ert Pbani1acy Services, Inc. (Alert) is the preferred pharmacy for the Community. In conjunction with Alert, the Community will assist You in ordering and stoling medications prescribed for self-aclm.tnistration. Medications are packaged in a Med-i-set container for safety"and ease of use. When the Community is responsible for assisting You with Your- medications, for Your safety, both prescribed and over-the-counter .. medications will be stored by the Community rather than in Your Apartment. '''.Alert accepts and bills all pharmacy insurance plans that permit it to serve as a pharmacy prOvider for plan members. To determine whether Your insurance plan is covered by Alert, You should provide the Community a copy of the front and back of Your pharmacy plan or card, including the PACE Program. Mail order plans are accepted, subject to a seIVice fee. While the CoIIllIi'Uoity encourages You to use the preferred pharmacy, You may request the use of an alternate pharmacy under the following conditions: (a) the Community's medications policies are followed; (b) medications are dispensed in Med-i-set containers and delivered weekly to the Community; (e) the pharmacy supplies a medication administration record (MAR) on a monthly basis that is kept current with Your prescription medications; and (d) the pharmacy bills You directly. You agree that failure of the alternate pharmacy to follow these policies may result in revocation of an exception by the Community by giving You seven (7) days 7 notice in writing. Requests should be submitted to the "Admirtistrator in writing. 7. Health Records. You authorize the COlllOlunity to make available to its staff and agents on a need-to-know basis any personal or medical records prepared or maintained by the Community. You also authorize the release . of the records prepared by the Community to any other healthcare provider from whom You receive treatment and to third party payors of health services. .The Community has a privacy policy that further outlines when and how Your health information is used. This policy is contained in a handout in Your admission packet. Otherwise. YoW'records shall remain 'Confidential and shall be made available only to You) Your authorized legal representative or authorized agents of the state or federal government, such as the Long Term Care Ombudsman. Except in accordance with Your express written consent, a subpoena, judicial order, 4 Rx Oate/Time . SEP-27-05 10:09 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 7175331014 P.007 T-149 P.007/045 F-748 provider agreement or other applicable provisions of law, Your personal and health information will not be supplied to other than the aforementioned persons or entities. !" 8. Exclud.ed Services. In addition to the Community's' charges, You are responsible for paying all legitimate fees and costs for goods and services furnished to or for You by anyone other than tl?e Community unless covered in full by Medicare or other third p~ payors. You are obligated to pay such fees and costs whether the goods and .services are furnished by someone' referred by the Community or by a per~on ~r provider selected by You. These fees and costs are not included in Your Customized Service Rate. Fees for professional services rendered by a physician, therapy . company or other service providers, including those covered by Paragraph VI (DL are not included in Your Customized Service Rate and will be ~harged directly to You by the hea1thcare provider. 9. Medicare Coverage. Whenever eligible for coverage, You agree to purchase Medicare Part B and Medicare Supplemental Insurance or HMO Medicare Coverage while a resident of the Community. u. FEES , A. Customized Service Rate. The monthly CustoriUzed Service Rate is ($ 2..<089 )( ('~/O )*, which applies to the service;leve1 checked on Page One (1). This amount is due and payable one month in advance by the fifteenth (15th) day of each calendar month. Any balances unpaid within forty-five (45) days of the date of billing, including Charges for services or supplies not included under the Customized Service Rate, will be assessed intere5t at the rate of one percent (1%) per month. 'Your rights to occupy and use Your Apartment and to receive other services under this Agreement are contingent on Your timely payment of Your Customized Service Rate. The items included in the Customized Service Rate are listed in ~hi~it "B" to this Agreement. Charges for services or supplies not included in Your Customized Service Rate are listed in Exhibit "C." B. Adjustments 'to Rates. The. Community shall have the right, upon thirty (30) days prior written notice to You, to acijust Your Customized Service Rate and to amend other fees and charges. As otherwise provided in this Agreement, Your Customized Service Rate will be adjusted concurrently with any increase or decrease in Your level of service. c. Absences from. ComDlunity. You are responsible for paying Your Customized Service Rate, even when You are absent from Your Apartment. When You are absent for five (5) days or more, The Community will deduct .a5.00 per day from Your Customized Service Rate retroactive to the first day. Whenever the absence is due to m.edical needs, (i.e., skilled nursing or acute care) the Community will deduct $S.OQ per day beginning with Your first day of absence. rr For Office Use Only - Accounting Charge Code 5 . Rx Oat:>/T i me SEP-2T-05 10:09 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 T]T5331014 P. 008 T-149 P.OOS/045 F-T4S UL 1,6 D. Community Fee. Prior to admission to the Community, You must pay a Community Fee. The Community Fee is used to help defray costs of entering and leaving the Community including cleaning and refurbishment of Your apartment, initial resident assessment,. customer service planning, and completion and processing of Your admission documentation. The Community Fee is $2,000 for a married couple and $1,500 for a single or unaccompanied resident. ,. Upon Your discharge from the Community, for whatever reason, a portion of the Community Fee may be refunded to You. IiYou give the Administrator written notice of intent to leave or if You are asked to leave within seventy- two (72) hours of admission, You will receive a full refund of the Community Fee; if You are discharged following a stay of more than seventy-two (72) hours but less than 90 days, You will receive a refund of $750; ifVou leave following a stay of 90 days or longer, the balance of the fee will be retained by the Community. Married couples are eliglole for refupds when both residents have left the Community within the specified time period. Your length of stay includes the day of admission but not ~e day of discharge. So long as You continue to occupy an Apartment, temporazy absence from the Community fOTa::personal or medical reasons (e.g., taking a vacation or a hospital or nursing home stay) does not' amount to discharge. Refund of Your Community Fee will be subject to payment of Your Customized Service Rate and aU other applicable charges owed at the time of discharge. Refw1ds will be made within the period prescribed by state law or within thirty (3D) days of the date Your apartment is vacated, whichever comes first. In the event that Yow- discharge from the Community coincides with Your admission to a CountrY Meadows long-term care facility on either the Bethlehem or South Hills campus, You will receive a standard refund of the Community Fee as described above. If You return to an assisted living Apartment follOwing a stay in our long-term care facility. a second Community Fee will be waived. ADMISSION A. Non-discrimination Policy. It is the Communit:ys policy to comply with allloca1, state and federal laws and regulations. The Community does not diScrjf1::J1Tlate in Resident admissions on the basis of race~ ancestry, color, religious creed, age, sex:, handicap, disability or national origin1 provided the Resident, in the sole opinion of the COIIlUll.inity. can be cared for legally and responsibly. Suitemates in shared ApartInents are selected according to sex and their cognitive and physiCal abilities. Otherwise, Apartment assignments and transfers, as well as Resident" care, are carried out without . regard to race. ancestry. color, religious creed, age or national origin. B.. Accuracy or Admission Documents. You understand and agree that Your application, statement of finances, health history and medical report, medications, personal interview, emergency information records, copies of . Q:< Da.tf' IT i me SEP-27-05 10:09 SEP-27-2005(TUE) 09:38 FROU-HOFAX2FL 7175331014 7175331014 P 009 T-149 P.009/045 F-748 Your Social Security card, Medicare card and any pharmacy insurance plan or PACE card, if applicable. are a part of this Agreement. Any material misrepresentation or omission made by You as. to Your fin:iI\pial resources or health history shall render this Agreement voidable at the option of the Community. You agree to submit updated copies of the above information from time to time as changes take effect. IV. CHANGE OF ACCOMMODATIONS A. Semi-Private Occupancy 1. SUitemates Who Are Not Couples. The Community permits semi-private oCQUpancy of selected Apartments. If You QCcuPY the Apartment with a friend. relative or other suitemate. in the event of the transfer or death of o~..e of You during the term of this Agreement. the remaining Resident may stay in the Apartment upon payment of the then CUlTent Customized Service Rate for "special private" occupancy of the Apartment or. upon acceptance of a: suitemate, the Rate for shared occupancy. If the remaining Resident wishes to transfer to an Apartment designated for "private" occupancy~ You may do so when one becomes available. The then current CustomiZed Service Rate for private occupancy will apply. In the event that the Community is unable to provide a suitemate satisfactory to You after two tries~ You shall have the option to occupy Your Apartment privately at the "special private" Customized Service Rate or to find~ within two (2) weeks of notice to You, a swtemate who is suitable for Your level of service. 2. Married Couples. The Community encourages shared occupancy of Apartments by married couples. If You occupy the Apartment together, in the event of a change of service level or the discharge or death of one of You during the term of this Agreement~ the remaining Resident may; remain in the Apartment. Your new Customized Service Rate will be based on "private" occupancy. B. When Community Dr State Regulations Require You to Move. The ~ommunity makes availa1;Jle to You independent living or personal care accommodations in separate wings or floors. either within this facility or an affiliated facility on tlie same Campus. Your application and Page One (1) of this Agreement indicate the Community's service level s.elected by You. When You need or desire per~onal care assistance not ofIered in the service level agreed upon byYou and the Community. such assistance may be available elsewhere within the Community. Following are descriptions of the various levels of service and when a transfer to ano~er level of serna: is appropriate; 1. Inclependent Living. This level of service is not licensed by the Commonwealth of Pennsylvania. In independent living1 the Community ~ 7 . ,Rx Da.t~lTime SEP-Z7-05 10:09 5EP-27-2005(TUE) 09:38 FROM-HOFAXZFL 7175331014 7175331014 P. 010 T-149 P.OIO/045 F-748 provides You with the main meal daily) weekly light housekeeping of Your Apartment) scheduled transportation to medical and dental appointm.ents and shopping) a social and activiti~s program) and round-the-clock emergency response by a trained staff member. The person responsible for emergency response may be located in an adjacent building. When You need one or more of the types of assistance provided in another level of service for a period exceeding thirty .(30) days, it will be necessary for You to transfer to an Apartment in that level. Based on the extent of assistance needed and/or consideration of Your ~afety and well being) Your transfer could take place in less than thirty (30) days. Your level of service will be determined by a physical and cognitive assessment by the staff of the Community who will assist You in moving to an Apartnient in the appropriate level. While the Community is providing these .ft additional services, You will be charged accordingly, until such time as You move to the next level. . \.i 2. Basic Assisted Living. This level of service is licensed by the Commonwealth of Pennsylvania and provides three meals daily, as well as assistance with one or more of the following personal care services: · Personal HY'~ene · Tasks of Daily Living · Medication Management · Supervised Care When You need extensive assistance with. any of the personal care services listed above, require routine assistance with ambuIation, or require a more structured environment due to memoIy los3) it will be necessary for You to transfer to a higher level of semce. The level of service required will be determined by a physiCal and COgnitive assessment by the staff of the Community who will assist You in moving to an Apartment in the appropriate level. 3. William PeJm. nus level of service is licensed by the Conunonwealth of Pennsylvania for personal care and provides all sezvices offered in Basic Assisted Living along with the following: a higher level of support services .' including assistance with ambulation, dining) contlnency management, personal laundry, grooming) personal hygiene and restorative physical care. s 4. Meadows. This level of service is licensed for Personal Care by the Commonwealth of PennsylVania to provide supervised care in a secure setting. Those needing this level of service will eXhibit a degree of memory loss and! or other cognitive deficit sufficient for their attending physician to order care in a secure physical setting. In such a secure setting, You will have access to and must enter a 3 or 4~digit code on a touch pad mounted on the wall in order to leave the Meadows wing. When residing Rx DatelT i me , .". SEP-27-05 10:09 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 7175331014 P.Oll T-149 P.011/045 F-748 ,-, on this wing, You ar-e able to leave the secure section when accompanied by a friend7 family member or staff member who is authorized to accompany You. outside the wing. Also. You will have access to a yard with sidewalks during daylight hours except in inclement .weather. In. this level of service, the Communitr provides all services in Basic Assisted Living along with the following: a higher level of support seIVices intended to assist You in participating in a fulfill!l1g.social and activi~es program; management of coIltinency and personal hygiene; and validation of YoUr feelings which can help to maintain se1f-es~eem and avoiq depression. 5. Long.Tenn Care/Skilled Nursing Care. When You require skilled nursing, it 'Win be necessary to transfer to a long-term care facility in the event these services cannot be provided at the Community by an approved Hospice or Home Health Agency. The need for a higher level of service will be determined by Your physician or by a physical and cognitive assessment by the staff oithe Community who are available to assist You in finding an appropriate facility. . State regulations d6 not permit a personal care facility to care for residents who are permanently confined to bed.. have a third stage decubitus (i.e., bedsore), or require a feeding tube (unless self-managed), intravenous therapy, or services on a routine basis nonnalIy provided by a long-term care fa.,cility. Other conditions that could require a higher level of service include but are not limited to special dietary restrictions, dysphagia, unmanageable incontinency, contagious diseases or psychiatric conditions that are not manageable in a.personal care setting. On its South Hills and Bethlehem campuses, the Community has skilled nursing facilities licensed by the Pennsylvania Department of Health to provide skilled nursing care. As a resident of the Community, You would be offered priority admission to one of the facilities should You need this level of care and if an appropriate room is available. Please understand that the Community cannot guarantee Your admission, or date of acimission, to one of its nursing centers, nor are You under any obligation to consider or use its nursing ceIlt~s. To be considered for admission, You should contact the Admissions. Director of the a~p'ropriate facility in order to discuss admission. . requirements and determine a possible admission date. . 6. Choosing to Leave tJle Community. Should You choose not to transfer to a higher level of service within the Conununity when Your assessment of physical and cognitive abilities indicates the need, th~ Community will attempt to support You in-house until You can make other arrangements. Ordinarily You have a period of thirty (30) days to make other arrangements 9 . RxOa.tp./Time SEP-Z7-05 10:10 5EP-~7-2005(TUE) 09:38 FROM-HOFAXZFL 7175331014 7175331014 p, 012 T-149 P,OlZ/045 F-748 from the date You are notified of the need for a higher level of seIVice. However, where the COlnDlunity believes there is a si~cant risk of harm to You or other members of the Community, Yo~ may be asked to move immediately. During the interim, You will be char~ for the additional assistance You require. v. ACCESS TO YOUR APARTMENT The Communitjrs staff may enter Your Apartment at reasonable times and for reasonable purposes, including inspection, maintenance and other services described in this Agreement. Every effort will. be made to notify You when a Community employee will enter or has entered Your Apartment for non-routine evep.ts. In addition, a duly authorized Lic~nsing Representative of the State Department of Public Welfare, after providing'proper identification and stating the purpose of his or her visit, may enter and inspect the entire Community, inchiding Your Apartment, at any time without advance notice. VI. " ',' 10 '~ RIGHTS AND RESPONSIBILITIES A. Rules and Regulations and Other Exhibits. You agee to abide by and conform. to the rules, regulations and policies as they now exist for the operation and management of the Community and such reasonable amendments to the above as the Community may subsequently adopt. A copy of the Community's Rules and Regulations is provided with this Agreement as Rvh-ibit "J)" and is incorporated by reference as a part of this Agreement. You also shall have the rights set forth in the Statement of Resident's Personal"Rights, which is attached as Exhibit "E" and made a part of this Agreement. Exhibit "P," Personal Inventory of Belongings, is a form to assist You in planning what You want to bring with You. This is a record that would be helpful in the event You were: to make a c1~im on Your insurance, should You choose to carry renter's insurance. It is not necessary to complete this form before signing this Agreement. It is a variable personal record, and You need only acknowledge that You received the form. Your Customer Service SUInmaIy, outlining the services,and support You need or request and which the Community agrees to provide, as well as Your Customized Service Rate, is attached as Exhibit "G. " B. No Proprietary Interests. The rights and privileges granted to You do not include any right, title or interest in any part of the personal property, land~ buildings or improvements owned or administered by the Community. Your rights are primarily for services, with a ~ontractua1 right of occupancy. Nothing contained in this Agreement shall' be construed to create the relationship of landlord and tenant between the Community and You. c. 'Absences. You are free to leave the Community at any time You wish, unless You are in the Meadows area, but the Community is not responsible for any obligations or ~enses incurred by You at such time. You agree to notify the Community in the event You plan to leave for an extended'period of time, ego vacations or hospit::!lH7.ations. ':' - .~x {)a1;rlTime SEP-27-05 10: 10 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 7175331014 P. 013 T-149 P.013/045 F-748 D. Emergency Care. In an emergency~ You agree that the Community may engage any licensed physician to attend to You. You hereby authorize such physician to render all such medical care deemed necessary. . ~"' E. Resident Responsibilities. In order to maintain Your good hea1th~ be an active member of the Community~ and promote the order and safety of Yourself and the Community~ You agTee to the following: to participate in all fire drills; to purchase and utilize Med-i-set containers for all Your prescribed medications; to comply with all published Community Rules and Regulations; to arrange for an annual medical evaluation or geriatric assessment; to anange for appropriate evaluations of Your potential for physical~ occupational and/or speech therapy when requested by the Community; to be' inoculated for flu and'.pneumonia unless advised otherwise by Your personal physician; to participate in the Community's Healthy Living Program that include educational and recreational activities; and to take meals routinely in the appropriate Community dining room to which You have been assigned. . VD. TRECOMM~SSTAFF The Community agrees to .provide~ at a minimum, the staff established by state regulations for Pers6nal Care Homes in order to provide the support services as set forth in Your Customer Service Sl~TT1rnary. This Summ.;uy is attached as Exhibit "G." While the Community attempts to have a licensed nurse on campus around the clock, this may not be possible due to illness, staff shortage or staffing priorities. At such times~ a trained staff member will be in charge and a licensed nurse will be available by telephone. VIIJ... TERMINATION OF AGREEMENT A. By You. You may terminate this Agreement at any time, with or without cause. by giving thirty (30) days' written notice to the Community through the Community's AdrniT\,;strator. Your notice must identity the date when the tennination is to become effective. which date must be at least thirty (30) days after the date of the notice. In addition. if You are transferred permanently to an outside facility because You need a level of care not. available at the Community, You may terminate this Agreement iinmediate1y upon vacating Your Apartment and removing all Your l?elongings from it. . B. By the Community. The Community may terminate this Agreement at any", time, without cause, by giving thirty (30) days' written notice to You and,. Your responsible person. if applicable~ In addition~ the Community may" terminate this Agreement for reasons including, but not ~ted to, the following: Your failure to pay the Customized Service Rate or additional charges . for seIVices within forty five (45) days of the date billed; Your failure to comply . with State or Local laws after receiving written notice of the alleged violation; Your failure to comply with the Community's Rules and Regulations as described in Section VI (A); a change in the use of the Community; or a 11 .,R.x Date/T i me SEP-l7-05 10:10 SEP-27-2005(TUE) 09:38 FROM-HOFAXlFL 7175331014 7175331014 P. 014 T-149 P.014/045 F-748 12 finding by the Community that the Community is inappropriate for Your care. Notwithstanding the foregoing~ the Community may terminate this Agreement at any time by giving You written notice to vacate immediately if You are engaging in behavior that is a threat to the mental and/ or physical health or safety of Yourself or others in the Community. If the Community should close to all Residents, the Community1s Administrator shall submit to You a written statement of the intent to close and the projected date, at least thirty (30) days before closure. Copies shall be provided to You, to the Department of Public Welfare) to Your emergency contact or designated person, to any agencies which participated in Your referral to the Community, and to any agencies currently providing services ~.to You. (This paragraph is required by s(ate regulations.) c. Vacating the Apartment and Your Refund. Upon termination of this Agreement under Section vm, other than by death, You or Your estate shall vacate Your Apartment, remove all of Your belongings from it~ and return all keys to the Community. Until Your Apartment is vacated and all Your property is removed, You shall remain liable for paying the Customized Service Rate. After Your Apartment has been vacated, the Community may remove any ofYoUF remaining belongings. and store them at YOUL" expense. Any portion of the Customized Service Rate which has been prepaid for a period during which the Apartment is not occupied by You or Your possessions will be refunded to You. D. Termination of Agreement UPOD Death of Resident. The Community acknowlegdes and. complies with the Elder Care Payment Restitution Act (Act 171 of 2002) which. establishes a manadatory refund policy for residents in the event of death while residing at a licensed personal care facility. In the event of death, :Your estate, personal representative or guardian shall remain liable for payment of the Customized Service Rate, less the cost of "elder care services" until Your personal property bas been removed from the Apartment. Elder Care Services are defined by law as "services or treatm.ent provided to meet a consumer's need for personal care or health care~ including, but not limited to, homemaker services~ assistance with activities of daily living, physical therapy~ occupational therapy, speech therapy, medical social servicesl home care aide service~~ companion care services, private duty nursing services~ respiratory therapy, intravenous therapy and in-home dialysis and durable medical equipment services, which are routinely provided unsupervised and require interacti:on with the consumer." Elder Care Services do not include room and board charges. Following removal of Your perso~a1 property from the Apartment, that . portion of Your prepaid Customized Service Rate related to "elder care services. will be refunded to Your estate, personal representative or guardian within thirty (30) days of the date Your personal property is removed. As provided in Act 171 of 2002, the Community must attempt to contact Your representative or guardian within 24 hours oflearning of Your death. to .'.... ", · Rx ,-Oq,telT i me SEP-27-05 10:10 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 7175331014 P. 015 T-149 P.015/045 F-748 arrange for an inventoIy of Your personal property. Following the inventoryJ the Community may choose to store Your property or to leave it in Your Apartment. If the Community chooses to store the property, a fee cannot be charged. If after thirty (30) days the personal property is. hot claimed and disposal is being considered, the Community must send a notice by certified mail to Your estate, personal representative or guardian giving another fourteen (14) days to claim the property. If still unclaimed after this period, the Community is permitted, but not required, to ~dispose of the property. Act 171 ~f 2002, permits a disposal fee to be charged by the Community. The above-described provisions of the Elder Care Payment Restitution Act apply only in the event this Agreement is terminated by death. They do not apply to those residing in Independent Living apartments or to a refund of the Community Fee described in Paragraph n D of this Agreement. E. Release from ObligatioDs. Any termination of this Agreement under Section VIII shall terminate the Community's obligation to furnish accommodations and selVices to You. Upon payment of any refund provided for above~ the ' Community shall be discharged from any further obligations to You or Your estate under this Agreement. _.: IX. LIABILITY FOR PROPERTY DAMAGE You agree to maintain Your Apartment in a clean, sanitazy and orderly condition. You agree to reimburse the Community for repairs to Your Apartment and{ Or damage to carpeting, fump;liings and fixtures in Your Apartment beyond ordinazy wear anc;i tear. x. RESPONSmILITY FOR LOSS PF RESIDENT PROPERTY The Community is not responsible for loss of any property belonging to You due to theft or any other cause unless such loss is proven to have been caused by the negligent or intentional acts of the Community, its employees or agents. If You choose to purchase'insurance to cover possible damage or loss of Your property, You shall be responsible for paying for and maintaining such insurance. The Community strongly recommends that You keep only small amounts of cash on hand; items of significant monetary or personal value sh:ouId be kopt under lock and key. The Comm11Dity's Business Omce is available to c:ash personal checks amounting to $50.00 or less. ". .... XI. ADVANCE DIRECTIVES . , It is the policy of this Community-to accept Residents. advance directives. These include healthcare powers of attorney, living wills, doctors' orders regarding CP~ or. other documents which describe the amount, level or type of health care You wish to receive at a time when You no longer can conununicate those decisions directly to a doctor. Also included are documents in which You name another person who has the authority to make healthcare decisions for You. If 13 .Rx Oate/Time SEP-27-05 10:10 SEP-27-2005(TUE) 09:38 FROM-HOFAX2FL 7175331014 7175331014 P. 015 T-149 P.016/045 F-748 CAPACITY OF RESIDENT AND GUARDIANSHIP Should You become unable to understand or comm~cate healthcare decisions and be determined to be incapacitated by Your physician or the Community's Medical Director, the Community shall have the right to take the following steps in the absence of Your prior designation of a legal representative to act for You: commence a legal proceeding in a court of competent jurisdiction to judge Your legal caplcity and, when appropriate, have the court appoint a guardian. The cost of the legal proceedings~ including attorney's fees, shall be paid by You or Your estate. (Copies of powers of attorney documents should be provided to the Community upon adnnssion for Your health information file.) ENFORCEMENT OF 'tms AGREEMENT Failure of the Community in one or more instances to insist upon Your strict performance of, obseIV'ation of, or compliance with any of the terms and provisions of this Agreement shall not be construed to be a waiver or relinquishment by the Community of its right to insist upon strict compliance by You with all of the other terms and provisions of this Agreement. ASSIGNMENT You agree not to assign Your interest in this Agreement. XV. FAMILY VISITS XII. XIII. .,: XIV. 14 You have executed any such documents, or ifVou execute any such documents while You are living at the Community, it is Your respon~ibility to advise Community staff of this and to provide a copy of any such documents to the Community. If You have such documents and You have p.f.ovided a copy to the Community, the Community will make its best efforts to provide copies of these documents to healthcare professionals who may be .called to assist You with healthcare. If You execute such documents and later revoke or change them1 it is Your responsibility to inform the Community of such revocation or change. In the event You do not wish to receive cardiopulmonary resuscitation (CPR) in a medical emergency, You' may purchase a "NO CPR1JI 'bracelet or necklace. The bracelet or necklace, engraved with Your name, is available through Alert Pharmacy Services and will help others be. aware of Your wishes'. The Community encourages family and friends to visit You, subject to the Community Rules and Regulations. The Community encourages,regular family involvement with You and provides ample opportunities. .rOr families to partiCipate in activities at the Community. You may have visitors at any time. The Community asks that visitors and f~y members be considerate of Your suitemate whenever applicable. Normal Business Office hours are 9:00 a.m. to 5:00 p.m., seven days a week. - .. -Hx"2atn/Time SEP-27-2005(TUE) 09:38 FROM-HOFAXZFL 7175331014 7175331014 P. 0 17 T-149 P.017/045 F-74B SEP-Z7-05 10:11 XVII. XVI. GOVERNING LAW This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania and shall be b~f.lding upon and inure to the benefit of each of the undersigned parties and their respective heirs, personal representatives, successors and assigns. 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 a~strative body of proper jurisdiction and authority to be invalid, the other provisions shall remain in full force and effect as if the invalid provision bad not been a part of this Agreement. _' XVIII. ATTORNEY'S FEES ... In the event any action is brought by either party to enforce or interpret the terms of this Agreement~ the prevailing party in such action shall be entitled to its costs and reasonable attorney's fees from the non-prevailing party, in addition to such other relid as the court may deem appropriate. XIX. SUBMITTING CONCERNS OR SUGGESTIONS ~ . The Community welcomes Your input on how we are doing and where improvements can be made. You or Your personal representative are encouraged to forward suggestions or concerns to the Administrator of the Community. Your suggestions or concerns can be communicated directly or mailed to the Administrator at the adQress for notices in Paragraph A on Page One (1) of this Agreement. . You also are encouraged to participate in the Community's monthly Fireside Chats and any Customer Satisfaction Surveys, both of which provide an oPPOrtunity for Residents to make suggestions and to voice concerns. Our goal is to provide approp:cia.te services for all Residents. There shall be no retaliation against a Resident or personal representative who submits a concern. xx, RELEAsE OF LIABILITY It is the CommUDity's policy that each Resident maintains his or het' freedom and independence to the greatest extent feasible. Residents are eucolUaged to exercise judgment ill decisions of enryday life and to make choices that enhance the fuUness a.a.d quality or their lives. ' '. Concurrently, decliues in function Dlay occur that are gradual and not.: .. apparent until an accident or ugury Occurs. You and the ComDlunity acknowledge that as a result of such declines, old.er adults are more likely to have accidents, such as falls, and are more prone to be injured. Recopizing thi3 izu;reased. risk of accidents among older adults, You. acknowledge that it is not possible for the 'CODUnuS'lity to prevent all Resident faU51lAd sfft1;l~J' accidents that may be due to declines in strength and balance or loss of visual acuity. Further, You agree to release and hold 15 r- .' , r i. r I. - '(x"Oat'2ITime SEP-Z7-05 10:11 SEP-27-2005(TUE) 09:38 FROM-HOFAXZFL 7175331014 7175331014 P. 018 T-149 P.018/045 F-748 the Commumty harmless from ac~ideDts and injuries that result from Your decisions that exercise Your freedoDl and independence, in spite of the higher risk of accidents. XXI. NOTICES Notices required by this Agreement shall be in writing and delivered either by personal delivery or mail. If delivered by mail, noti~es shall be sent by U.S. Postal Service, with aU postage and charges prepaid. All notices and other written communications required under this Agreement shall be addressed as indicated below, or as specified by subsequent written.notice by the party whose address bas changed. A. ~F TO COMMUNITY. Notices to the Co~unity should be addressed to "Administratorl" Country Meadows Retirement Community, at the address set forth under Paragraph "AI' on Page One (1) of this Agreement. ... :., B.. IF TO RESIDENT(S).. Notices to the Resident(s) should be addressed as follows (if notices are to be directed to a Responsible Person and not to the Resident, please enter that person's name and address): ~,~/ll ~ iclU.h . 0 ~'" qo ~lLlf~-) eA 170~ XXII. PERSON RESPONSIBLE FOR ADl\UIfISTERING PAYMENT If someone other than the Resident will be responsible for administering payments for the Resident's stay at the Community, please enter that person's name and address. Please note that the Community will not attempt to impose a financial obligation on anyone otp.er than the Resident or his or her estate. ~elck~h ~qO I-td I~I PA J"7Q3i;}- . XXID. ACT 171 CONTACT PERSON For purposes of the ElderCare Payment Restitution Act (Act 171 of 2002)) the contact person for the Resident will be the following (please enter that person's name and address). Qe~e Ickkh ~(J-'66L q 0 H-a..1 \ ftuc., pr; 17~ . 16 ">. ..... - SEP-Z7-05 10:11 5EP-27-2005(TUE) 09:38 FROI.l-HOFAXZFL I , F1 X"J a.t 2/T i me 7175331014 7175331014 P. 019 T-149 P.OJ9/045 F-748 XXIV. REVIEW BY YOUR ATTORNEY This is a contract. It has numerous provisions that affect Your legal rights. It is strongly recommended that You ask an. attorney to review this Agreement before You sign it and answer any questions You may have. XXV. VOLUNTARY AND AUTHORIZED EXECUTION .By signing below, You and/or Your Responsible Person signify that You have read the terms of this Agreement, fu11y un~erstaDd its tenus, are voluntarily agreeing to those terms, and.. iatend to be legally boW1d. If executing as RespoDsible PersoD~ You 'hereby certify that You are authorized to sign on behalf of the Resident(s). .. . IN WITNESS WHEREOF, the Community and You have executed this AgreemeIlt in duplicate. RESmENT(S) (Please prin.t): Name: Address: By: .iI I~L~ i:J ~ Signature of esident Date By: Signature of Spouse, if applicable RESPONSIBLE PERSON, if applicable (Please print}: Name: ~Id.(.sh Address: P D Box. q 0 ~"" I ~) PA 1'0.3=1- Telephone: a2.L 0 - 0 0 'fl./. Relationship to Resident: ~Gy) Date ~. ~ /~,..~ y' ~ignature BE COM1\/WNITY (please print): Name:~nY\ SOlAJ~ Title: bt rec.tov or ma.v-k.et(~ By: \..~~"'~ Signature Date -,. lofli/at.{. Date 17 -