Loading...
HomeMy WebLinkAbout06-5366 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEALTHCARE CORP. d/b/ a MANORCARE HEALTH SERVICES- CAMP HILL, Plaintiff, No. Ol.. -S.3Lb ~o~LI~ v. GAYLORD THOMPSON, Defendant. CIVIL ACTION - EQUITY NOTICE YOU HA VE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU 00 NOT HA VE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAYBE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association 32 S. Bedford Street Carlisle, PA 17013 (717) 249-3166 (800) 990-9108 ORIGINAL IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. No. GAYLORD THOMPSON, Defendant. CML ACTION - EQUITY A VISO USTED HA SIOO DEMANDAOO / A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y A viso radicando personalmente 0 por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se Ie advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demand a 0 cualquier otra reclamacion 0 remedio solicitado por el demand ante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero 0 propiedad u otros derechos importantes para usted. USTED DEBE LLEV AR ESTE OOCUMENTO A SU ABOGAOO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGAOO, LLAME 0 VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGAOO. SI USTED NO PUEDE P AGAR POR LOS SERVICIOS DE UN ABOGAOO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION saBRE AGENCIAS QUE OFREZCAN SERVICIOS LEGALES SIN CARGO 0 BAJO COSTO A PERSONAS QUE CUALIFICAN. Cumberland County Bar Association 32 S. Bedford Street Carlisle, P A 17013 (717) 249-3166 (800) 990-9108 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYL VANIA MANOR HEAL THCARE CORP. d/b / a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. No. 0(,- 53(,(, ~ T~ GAYLORD THOMPSON, Defendant. CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b / a ManorCare Health Services - Camp Hill, ("Plaintiff ManorCare"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the within Complaint against Defendant, Gaylord Thompson ("Defendant Thompson"), and in support thereof, provides as follows: 1. Plaintiff ManorCare is a Delaware corporation licensed to do business in the Commonwealth of Pennsylvania, with offices located at 1700 Market Street, Camp Hill, Pennsylvania 17011. 2. Defendant Thompson is an adult individual who currently resides at 2600 Wilson Parkway, Harrisburg, Pennsylvania 17104. 3. On or about February 27, 2006, Defendant Thompson made application for admission on behalf of his mother, Rosa Thompson ("mother"), to Plaintiff ManorCare's skilled nursing facility located at 1700 Market Street, Camp Hill, Pennsylvania 17011. 4. On or about February 27, 2006, Pla.intiff ManorCare and Defendant Thompson entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff ManorCare agreed to provide his mother with skilled nursing care and services in exchange for his promise to pay a specific monetary fee from his mother's assets; and, in the event that Defendant Thompson's mother lacked sufficient funds to pay for the said care and services provided to her by Plaintiff ManorCare, Defendant Thompson further agreed to make timely and proper application for Medical Assistance benefits on his mother's behalf when she became eligible for such assistance, including pursuing any subsequent appeals if said application were denied. A true and correct copy of the Agreement is attached hereto as Exhibit" A." 5. Shortly after her admission to Plaintiff ManorCare's skilled nursing care facility, Defendant Thompson's mother allegedly became insolvent. As a result, pursuant to the Agreement, Plaintiff ManorCare notified Defendant Thompson of his contractual duty to make application for Medical Assistance benefits on his mother's behalf. Subsequently, an application for Medical Assistance benefits was filed on behalf of Defendant's mother. 6. The application for Medical Assistance benefits referenced above was denied on September 5, 2006, because Defendant Thompson failed to provide to the Cumberland County Assistance Office those documents necessary to determine her eligibility for Medical Assistance benefits. See Exhibit "B." 7. On or about September 5, 2006, Plaintiff ManorCare appealed the aforementioned denial dated the same. 2 8. If Defendant Thompson fails to provide the documents requested by the Cumberland County Assistance Office to determine his mother's eligibility for Medical Assistance benefits at or before the hearing scheduled on the appeal filed by Plaintiff ManorCare, the application for Medical Assistance benefits referenced herein will be finally denied, and any further appeal to the Commonwealth Court to keep the application alive would be without merit. COUNT I BREACH OF CONTRACTI SPECIFIC PERFORMANCE Plaintiff ManorCare v. Defendant Thompson 9. The allegations contained in Paragraphs 1 through 8 are incorporated herein by reference as if fully set forth at length. 10. Defendant Thompson breached the Agreement with Plaintiff ManorCare when he failed to make complete application for Medical Assistance benefits on his mother's behalf, and Defendant Thompson continues to breach his Agreement with Plaintiff ManorCare by refusing to provide those documents needed by the Cumberland County Assistance Office to determine his mother's eligibility for Medical Assistance benefits. 11. Defendant Thompson's breach of the Agreement with Plaintiff ManorCare has irreparably harmed and continues to cause Plaintiff Manor Care irreparable harm. 3 12. Only a decree of specific performance will adequately protect the interests of Plaintiff ManorCare and provide it with the benefits and/ or protections promised under the Agreement. WHEREFORE, Plaintiff ManorCare seeks a decree from this Honorable Court which orders specific performance of the Agreement between the parties. Respectfully submitted, SCHUTJER BOGAR LLC Dated: q J I(;(JxCO lp ( f By~r::::::~ Attorney I.D. No. 83755 (717) 909-5920 Maria Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 305 North Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff 4 VERlPlCA. nON The undersigned hereby verifies that the statements of fact in the foregoing Complaint are trut:t and conrect to the best of my knowledge, inronnation and oolicl. I understand that any false statements therein are subject to the peNlties contQined in 18 Pa. c.s.A. 94904, relating to unsworn falsification to authorities. Dated: 1ilJO f" I . . EXHIBIT II A" f<.X U ate I I i m e J t I-' - I ~ - ~ U U b ( I U I:) I 0: 1 0 09/12/2005 10:15 7177372189 7177372189 MANORCARE,CAMPHILL P 002 PAGE 02 :. ,. ->. HeR Manor Care Pennsylvania ADMISSION AGREEMENT This Agreement is entered into by and among Nightingale Nursing Home, Inc., d.b.a. HCR Manor Care ("HCR Manor Care"), the Resident, and the Responsible Party, if any, for the purpose of providing for the rights and responsibilities of the parties with n~spect to the Resident's stay at this HeR Manor Care's Center ("Center"). Center: ManorCare Health Services, Camp- Hill Resident: f2,DSa.. ,ho yY\ pS 0 ,.J Responsible Party: &'0...,/ I DY'c9 --rho y"\oo... f..s O.,....J Admission Date: d-I;}, 7/ () (P Deposit: $ d, DC) Term: This Agreement begins on the day the Resident enters the Center and ends on the day the Resident is discharged unless the Resident is readmitted within fifteen (15) days of the Resident's discharge date. I. RIGHTS AND m:SPONSJBILITIES OF THE RESIDENT 1.01 Room and Board Rate. For the basic services provided for in Section 3.01, the Resident will pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and is due upon receipt. The Resident is responsible for the Room and Board Rate for the day of admission a~ well as the day of discharge, This Section will not apply jf the Residen't is covered under a governmental program (see Section l.05) or by a third party payor or managed care organization (see Section 1. 06). 1.02 Ancillary Charges. The Resident will pay to Center. all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or. provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such" Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges will be included in the Resident's statement for the succe.:eding month, and are payable in full, along with the Room and Board Rate upon receipt. Rx Date/Time SEP-12-2006(TUE) 10: 10 09/12/2006 10:15 7177372189 7177372189 MANORCARE,CAMPHILL P 003 PAGE 03 " , . ,':;,;'~- '- ~-, :~', ',;' , },03 ColIectionslLate Pa;ments. Payment is due in fun within thirty (30) days of billing. Should the Resident's account for any reason be turned over for collection, the R(~sident will pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident is directiy responsible: 1:0 independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center will accept payments under such program in accordance with the terms of the program as set forth in the contract the Center has with the program, The Resident is responsible for any co-insurance, deductibles or ncm"cClvered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements, In the event the Resident's coverage under the governmental program( s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections] .01 and 1,02. The Center participates in the following programs: _,,_Medicare, _x_Medicaid andlor _V A. Medicare may pay for some or all of the Resident's care, If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident agrees to pa.y any required deductible, any required co-insurance, and any non-covered services according 1:0 the same terms and conditions applicable to private pay residents. The Resident and/or Responsible Party are responsible for. applying for Medicaid. If the Resident receives Medicaid, ml)S1 of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income, The Resident agrees to pay on a timely basis, as set forth in this Agre(:m.ent, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident fails to pay the contribution amount, the Center ma,y take such legal action as necessary, including requesting a court to order such payment, 1,06 Third Party Payors and Mana~d Care Organizations, If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMOtf), Preferred Provider Organization ("PPOtf), Provider Sponsored Organi.zation (tfpSO"), or ,Physician Hospital Organization ("PHO"), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicnble agreement. The Resi.dent is responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center 2 R.x 0 ate IT i me 5 E P - 1 2 - 2 0 0 0 ( T U E) 1 0: 1 0 09/12/2006 10:15 7177372189 7177372189 MANORCARE,CAMPHILL P. 004 PAGE 04 '., will bill the Resident's third party payor as a service, but the Resident remains liahle for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident is responsible for paying the Cc~nter for items and services provided during the stay at the Center and during which time the Rtsident has not, been determined to be eligible for any governmental program or covered under any third party payor or managed care organization plan. The Resident and/or Responsible Party will notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Responsible Party will notify the Center in writing when application to Medicaid is made. The Resident andlor Responsible Party will cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center or to have payment made on the Resident's behalf, the Resident will be notified of the Center's intention to discharge the Resident for non-paymenrin accordance with this Agreement, Resident Handbook and state and federal laws. 1.08 Admission Infonnation. The Resident and/or Responsible Party will notify the Center and provide any needed information regarding all third party payors or governmental coverages on admission and throughout the Resident's stay including copies of insurance cards, identification or verifi,cation of eligibility and coverage information. The Resident and/or Responsible Party will provide the Center in writing with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident acknowledges that if tho Resident fails to provide such information, the Resident may be responsible for. any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 Application for Benefits. The Resident and/or Responsible Party will apply for coverage and to establish eligibility under any governmental, third party payor, m~lOaged care or private insurance program. The Center has no obligation to bill any third party payor other than the Responsible Party and, when applicable,' a governmental program third party payor or managed care organization with which the Center is under contract. 1..10 Primalj' Responsibility for Payment. Ex-cept for payments for services covered under governmental programs or other third party payor provider agreements, the Resident remains primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Responsible Party acknowledge that the insurance company, HMO, P,PO, PSO, PHO or managed car.e provider may not pay for non-covered services, supplies, equipment. medications, and other care and services which may be delivered by the Center or its subcontractors. This agreement serves as a written notice that the Center h2s notified the Resident and/or Responsible Party that services provided at the Center may not be: covered by a 3 Rx Date/Time SEP-12-2006(TUE) 10: 10 09/12/2005 10:15 7177372189 7177372189 MANORCARE,CAMPHILL P 005 PAGE 05 .; ..:..,.. ; ......1. . :: 'l' .'. " .j. , . governmental payor, th.ird party payor or managed care organization. The Resident and/or Responsible Party will be responsible for non-covered services. A price list of services is maintained at the Center's business office and is available for review during regular business hours. ] . 11 Personal Physician. The Resident has the right to choose a pers(lnal physician. provided that the physician selected is properly licensed and abides by applicable law and the rules and policies of the Center. At the time of admission, the Resident must supply the Center with the nam.e of hislher personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Responsible Party must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide need~d coverage and attendance or fails to abide by applicable laws and regulations, the Center Vvil! call another' physician to attend to the Resident and the fees charged by such physician will be borne by the Resident. 1.12 Pharmacy. The Resident and/or Responsible Party has the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with state law, abides by the Center's policies and procedures and has a medicati.on distribution system similar to the Center's ancillary pharmacy's medication distribution system, n. RIGHTS AND RESPONSmrLITY OF THE R.ESPONSIBLE PARTY 2,01 Legal Authority, The Responsible Party represents that he/she has 1c:gal access to the Resident's income or resources and that the documents supporting such autho:-ity, if any, have been delivered to the Center. 2.02 agreement to Make Payments on Behalf of Resident. The Responsible Party will pay promprly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Responsible Party will incur personal financi,ll liability on behalf of the Resident should the Responsible Party fail to pay the charges for which the Resident is liable under the agreement from the Resident's income or resources, 2.03 Requested Items. The Responsible .Party will be personally liable fOI any services or products specifically requested by the Responsible Party to be supplied to the Resident, unless sllch services or products are covered by a governmental program, 2.04 Exhal!.sjion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid. the Resident and/or Responsible Party must notify the Center in writing and must promptly apply for Medicaid benefits. If the Resident and/or Responsible Party fails to notify the Center in writing or fails to file for Medicaid or provide such information as Medicaid representatives may require to qualify the Resident for eligibIlity to Medicaid, the Center may end this agreement and transfer or discharge the Resident f1)r nonpayment upon reasonable and appropriate notice, as provided in Section 4,06. rn addition, if [he Responsible Party fails to notifY the Center in writing or fails to file tor Medicaid in a timely 4 R.x 0 ate IT i me 5 E P - 1 2 - 2 0 0 5 ( T U E) 1 0: 1 0 09/12/2005 10:15 7177372189 7177372189 MANORCARE,CAMPHILL P 005 PAGE 05 and proper manner, the Responsible Party will be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. 2,05 Cooperation for Financial Assistance. If the Resident is eligible tbr Medicaid, the Responsible Party must provide such information about the Resident's finances as Medicaid representatives require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any Lack of cooperation. If the Resident and/or Responsible Party fail to provide such information as Medicaid representatives require for continued eligibility for Medicaid payments, and as a result Medicaid does not pay for the Resid~'t1t's care, the Resident may be discharged or transferred upon appropriate and reasorlable notice for nonpayment, as provided in Section 4.06. 2,06 Acceptance Upon DischarJte. Upon termination of this Agreement as provided in the Resident Handbook, the Responsible Party agrees to arrange and pay for the departure of the Resident from the Center. If after notice, the Resident is not removed as requc!sted, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Responsible Party, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident or immediately make medically appropriate alternative arrangements and to pay promptly all charges. 2.07 Additional Responsibilities. The Responsible Party will comply with the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement, Resident Handbook, and Attachments. 2.08 Misuse of Resident Funds. In the event that the Responsible Party misappropriates the Resident's income or resources or otherwise illegally transfers assets for purpo~es of avoiding the Responsible Party's obligation to make payments on behalf of the Resident undl:r Section 2,02 or for purposes of qualifying the resident for Medicaid eligibility, the Responsible~ Party may be liable to the Medicaid agency and/or the Center for care that should have been paid for from the Resident's income or resources. Such misappropriation of the Resident's income or resources may also result in the imposition of criminal or civil sanctions against the Responsible Party. ID. RIGHTS AND RESPONSmILITIES OF THE CENTER 3.01 Room and Standard Services, As part of the Room and Board Rate, the Center will furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such ()ther personal services as may be required pursuant to the plan of care prepared by the Resident'H physician and the Center, with the Resident's consent, for the health, safety and general weiI-being of the Resident, 3.02 Other Services. The Center win act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 5 R~ DatelTime SEP-12-200li(TUE) 10: 10 09/12/2005 10:15 7177372189 7177372189 MANORCARE,CAMPHILL P.007 PAGE 07 .,'X ~~~:'..:::''-': .~: '::'~f' . .! .; . 3.03 Deposit. The Center acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit wiD be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments will be paid by the Center within thirty (30) days after discharge or transfer or within the time frame required by State taw. In the case of Medicaid Residents, any such refund will be paid within t.hirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4,01 Consent to Release ofInformation. The Resident and/or Responsible Party hereby consents to the release of the Resident's medical records to the following persons: Center personnel, attending physicians and consultants; any person, firm, government entity, third party payor or managed care' organization responsible for all or any part of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the personnel of any hospital ()r other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 ~_onsent tq Treat. The Resident and/or ResponSible Pany consent to the use and disclosure of Resident's protected health information for the purposes of receiving treatment from the Center, obtaining payment for healthcare services provided to Resident, and the Center's own healthcare operation needs. The Resident and/or Responsible Party. by signing this Agreement, authorizes the appropriate staff of the Center to perform such functions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Responsible Party represents that he/she has the legal. authority to make health care decisions on behalf of the Resident, that documl:nts supporting such authority have been delivered to the Center, and that such Responsible Party consents on behalf of the Resident to the Treatment described above, 4.03 Consent to Photolp"aph. The Resident and/or Responsible Party consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services......f..2lifies and Additional Information. The Resident and/or Responsible Party acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, jf applicable. The Resident and/or Responsible 6 [;Ix Oate/Time SEP-12-200o(TUE) 10: 10 09/12/2005 10:15 7177372189 .:;t,,::,;~: ~'."" ',' ( 1 n3721 89 MANORCARE,CAMPHILL P. 008 PAGE 08 Party acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a, Assignment for Payment of Benefits. See Attachment C. b. SNF Medicare Determination Notice. See Attachment D. c, Medicare Secondary Payor Questionnaire. See Attachment E. d. At the request of the Resident and/or Responsible Party, the Center will maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds, A description andlor policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachments F-l and F-2. e. Center Supplement: 1, Policy and procedure on bedholds, election of bed holds and readmission. 2, Social Service Agencies and Advocacy Groups addresses and phone numbers, 3, Name, address and phone number of Ombudsman. 4. Location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control un.it. 5, The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. 6. Procedures, name, address and phone number on how to file a complaint with the state survey and cenification agency concerning resident abuse, neglect, mistreatment and misappropriation of property, f. The Resident Handbook. g. ResidentfPatient Rights. h, Medicareflvtedicaid information and display of such informatic.n including how t() apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. 7 P,x DatelTime SEP-12-2005(TUE) 10: 10 09/12/2005 10:15 7177372189 7177372189 MANORCARE,CAMPHILL p, 009 PAGE 09 ~~ 1. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HeR Manor Care's Limited Treatment Practices and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachments G-l and G-2. J. Privacy Act Notification. See Attachment H. k, Notice ofInformation Practices and Receipt of Notice ofInformation Practices, See Attachments I-I and 1-2, 1. Ancillary Services Management Form. See Attachment 1. 4,05 Assignment of Benefits. The Resident and/or Responsible Party request that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment C to this Agreement either to Resident or on Resident's behalf for any service furnished by or in the Center. The Resident andlor Responsible' Party authorize the Center and any holder of medical or other infonnation to release such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and to third pany payors any information needed to determine these benefits or benefits for rdated services. 4,06 lermination. Dischar~e and Transfer, This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Responsible Party may terminate this Agreement by providing the Center written notice ofthe Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident will be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice, If discharge or transfer becomes necessary because the Resident and/or Responsible Party or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate, investigate, which may result in prosecution. 4.07 Indemnification. The Resident will defend, indemnify and hold th(~ Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 8 KX Uate/Time SEP-12-2005(TUE) 10: 10 09/12/2005 10:15 7177372189 ~-!<:.. '.'.. 7177372189 , MANORCARE,CAMPHILL '" . '::::}(~ ::"~"~ ",: ;::":::~: ;~:~;~" .~. :".:"::";""",' .....', ',",.: .' ", . POlO PAGE 10 ....... 4.08 C~g~s in the Law. A11y provision of tbis Agreement that is found to be invalid or unenforceable as a result of a change in state or federa11aw will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law, mE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THI:V HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT A1'I"Y QUESTIONS HAVE BEEN ANSWERED TO mEIR SA TlSFAcnON. Signature of Resident: X:- Dale: .i?L-;;. -~6u.. Signature ofRespolUible party:r...~~~. Date: C). j;.'J )e <L Center Representalive~h Dale: _ d.-/;) .yOlo. EXHIBIT "B" P,002 ~. J.IIJlhe..cJ..aorl..S.AO e .2"'1 ' 1-800.259-0173 717-240-2700 . DEPARTMENT OF, PUBUC WELFARE . .. CUWSliRlAND COUNT( ASSlSTANCE OfFICE , . 33 WESTMINSTER DRIVE. : p, O. BOX 5lI9 I I .. eARl.lSu, PA 11013-0559 . . Aft9r thg first checIc whh:h may be a apec18I emowll yO<J will m:oive $ --I O'Tw~ifrJ'tOnth' ....,EJ.vlli:...Q;,;otftt\.'._..B.iii.ihif.~ii ....C1 Nii~ENs"i .Rx Oate/T!me ,. SEP-05-2006(TUE) -.~H"'-"~.n"16:.09- 05 .-. 10: 12 . PNFS1112.t.ot NOT'CE TO APPLICANT 10: 05 (717) 249-0919 . SENEFlT I D<~~€~~~:__.._-_._-,. I r;;tMEDlCAL Lp'ASS\ST ANCE FOOD 0. STAMPS You wiq rcccivs S il month from o You haw ~ p;I."'" ""y liobility af $ rer !he pl;'riQd I)IlIJI~nlng end ending for lha monlll(s) OJ than you win receIVe fOOll slampa in 1I1e amount of $ to 0 In 1116 Mall 0 Allhc eank . ')4 o Eftecuvs Oaie [jNURSING HOME CARE Laval 01 oare aU1llol!2ed you are ~ Ie p;:y S a mOtl!h -.rd your oare. o ~~~ES 0 ~~" /~'::~~t~Qril~G:~t-!~~~,~~.~;::::i~~{q.~~=~:He"i '~'~;~'i~~$~~::$!{)~..'~~~~:~~~1~#~;~tr~~~1~~~~;;~~~;:;:~~~?~~~;;~~~1~~~i.~~~1~~~~?i~~~~~~~~'~~.~;;~'~~~f.:~..~ ~;~~~~~,;:~;~'~;'i;t;.;.';'.':~:~..' ~'~.' :.: , ASST. FOOD ~l:: . 500, LINE . CHECK STAMPS A5ST, SEI'lVICI! NO. NAN~ ~lH, FOOD M~D. 5ee, CHECK STAMPS' ASST. SERVICE NAME ~' Xt:t!,$. A~~!g~ ~~S B~~N~T!'tJ~E~.BE~AU~~.QF l!i~:EQbl-9~Y!~J!',F.:Jl.p~,~['!D REG!;!L}iT1QtIS. ~ ~L~ \..;j)S ~.~t.~.~~ \~~LQ,'t... .~~l&~foc.~. , '. TOTAL GROSS MONTHL V INCOME $ [ GROSS MONTH!.. '( DepeNDENT CARE COSTS $ ~ GROSS MEDICAL COSTS $ l: Tete.phon'" WalerlSswagij B\!ctric a~rbageJi rash , ,GaB 41i1ity In$"oSlIation Oil Other ~ Gr.lOSS \IilLITY COSTSlUTlLlTI STANDARD' $ ;. RE'NTIMORTlaGE $ , TAXES $ INSURANCE COST ON HOIiE . $ . ~ TOTAL SHELTER COST S -:--:.:"':'!.....;~.,. ~f'.'-: .;7; ~ . .;:-.\ ~ -:"":'.:-....~-:-.....:'~ ~~;i7.., ,:..:{ ..~1~'';' .::":!.......~ .~!"":';".. ..... ::_Ni~:..:...~;::\... ;'. - '".. TOTAL GROSS UONTii1LY INCOME .. ; ~U.~;:p,O'diebQ~d/riia}!::~,~;;,DP.if.i.~:liqv8t.:',uri;;i}i; ~I~/~~:tt(e.,':;: . . ::~,;st;pl.aal.d- ,utility, ':,f1!Io'1Bnce, '''!!l,: ch,a..;E/m,e..; ,?h reapplie~~0>~ ~n,d:.:. ~n~.: ,: .. NCl' MONTHLY INCOMeJNeT SEMI-ANNUAL INCOME ,::';.;~~~iJIe.'!!J!:~~l~'2.~rJ:,~~;~,f1.!.9f.!!).g~fipff.~,...~':j,:!;\,:;,'~=.;~t:.~'\"'::;:,~'.:':, INCOME UMIT ! . ....... '. ,.. ~.:,., '.. . " : ~ .' ,," . : ,,' . : ~.~:'. . '.. :. ...",..:.. .... ,I . .. ~ '.,;;'. ..... '.,' ';'.:: , ,. . ~ ..' _. . . . ~':'u'. '. ~ .:...:...'.:......",.. .....': '.' ".' _". n', ..'" ',.:..:-. Nams $ $ $ $ $ S G OllS MONTHLY UNEARN;;OINCOME $ $ $ NamE: $ $ $ !l ~i .., 1 TOTAL GROSS I\IIONTHL Y INCOME $ ] . GROSS i\QON7HL V OE:PeNt;EN I CARE COSi'$ $ :j ~~t.::1i';;~:::~;:~:2":~.\~ ~~~~;~~fi~~~:~: ~~~~: ~~~~~~.:~::~~~~~.:y~~.~~~~~;~~ . ~~ :.: ~:::1( ~:~ ~~;)~; :~'; ;~ ~". '.' ~~. "~:'~ , ,:Ct~QJC~.~~Clt:~;,.,;,':";')':'}Nurn!iJe~9f...t'~~;~~~~~ ~l /1. ~ J !Ii $ $ Nam9 GROSS MONTIiL Y UNEAI'lNEO INCOME $ 5 $ $ $ $ :~ N . .....'.. _. .. . . .... ..,.....'.. 11000 ~ RECORO NUMBER r ~~ Icv-d Ihon'tf'3ar\ I .'l.. I 2/&00 Wlb~ rW~1 . 0'"' '-..0<.: 'l+Of'r ,:5 ~UI.~, . r. ., I r L ml.~ 1..)1A,J.,../} , q!~'bt:' 711';:;Ii.()-~76Y , - Worker's Signature ~ TE'lo.:phone Number I ~::~,"::',::?';"~:?;~r;::,~$)\L:'f,l,Etp;fS.A~t<I~!-:e:AT:::' i i~';. . tD~ jb.~ LEGAL SERVICES. INC, a IRVIN~ ROW CARLISlE. PA 170~3-30~g 717-243-9400 717-766-8475 .J f~ ;~~i-&.;~i~'~~~in~~~ifF~t~bfi:;(~~~~:~~:9~j~!F:~: ~.~~y~~:~.F~-',:., ~~~ . ~ ~ ~ ~ -) ~ ~ f -.0 J ; "\ l~'.f ("~, f.~) )1 " --1 --r-- :"11 ~--- , . ~,...-....; " c.. G ! ,',') o Affidavit of Process Server Court of Common Pleas, Cumberland County, Pennsylvania (NAME OF COURT) VS Gaylord Thompson DEFENDANT/RESPONDENT Manor He~'thcare Corp. PLAINTIFF/PETITIONER 06-5366 Civil Term CASE NUMBER I John Shinkowsky , being first duly sworn, depose and say: that I am over the age of 18 years and not a party to this action, and that within the boundaries of the state where service was effected, I was authorized by law to perform said service. Service: I served Gaylord Thompson NAME OF PERSON / ENTITY BEING SERVED with (list documents) Notice, Complaint by leaving with Gaylord Thompson self At NAME RELATIONSHIP o Residence 2600 Wilson Parkway Harrisburg, Pennsylvania ADDRESS CITY / STATE o Business - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ADDRESS CITY / STATE On October 06, 2006 DATE AT 7:21/W. TIME Thereafter copies of the documents were mailed by prepaid, first class mail on - - - - - - - - - - - - - - - - - - - - - - - - DATE from - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - CITY STATE ZIP Manner of Service: o Personal: By personally delivering copies to the person being served. o Substituted at Residence: By leaving copies at the dwelling house or usual place of abode ofthe person being served with a member of the household over the age of - - - - - - - - and explaining the general nature of the papers. o Substituted at Business: By leaving, during office hours, copies at the office of the person/entity being served with the person apparently in charge thereof. o Posting: By posting copies in a conspicuous manner to the front door of the person/entity being served. Non-Service: After due search, careful inquiry and diligent attempts at the address(es) listed above, I have been unable to effect process upon the person/entity being served because of the following reason(s): o Unknown at Address 0 Moved, Left no Forwarding 0 Service Cancelled by Litigant 0 Unable to Serve in Timely Fashion o Address Does Not Exist 0 other - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Service Attempts: Service was attempted on: (1) - - - - - - - - - - - - - - - - - - - - - - - - - (2) - - - - - - - - - - - - - - - - - - - - - -- DATE TIME DATE TIME (3)--------------------------- (4)-------------------------- (5) --------------------------- DATE TIME DATE TIME DATE TIME Description:. Age~Sex Male Race~Height 5' 10" Weight 165 SUBSCRIBED AND SWORN to before me this o~ day of COMMONWEALTH OF PENNSYLVANIA NOTARIAL SEAL DONNA M. WIERMAN, Notary Public Susquehanna Twp., Dauphin County My Commission Expires July 28, 2009 NOTARY PUBLIC for the state of Pennsylvania NATIONAL ASSOCIATION OF PROFESSIONAL PROCESS SERVERS FORM 2 s~, - <..,;.) ';:D" --:#. ~5 ." c,) r:- """".. '. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/ a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. No. 06-5366 GAYLORD THOMPSON, Defendant. CIVIL ACTION - LAW/EQUITY PLAINTIFF'S PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Plaintiff, Manor Healthcare Corp. d/b/ a ManorCare Health Services - Camp Hill, ("ManorCare") pursuant to the provisions of Pa. R.C.P. No. 1531, and makes the following Petition for Preliminary Injunction and, in support thereof, avers: 1. ManorCare filed a Complaint against Defendant Gaylord Thompson. 2. The Complaint sets forth a single claim against Defendant Gaylord Thompson relating, inter alia, to his breach of an Admission Agreement (" Agreement"). See Complaint, Exhibit II A." 3. The very nature of the breach of the Agreement, i.e., failing to determine the eligibility of his mother for Medical Assistance benefits by refusing to provide the documentation and participate in the Medical Assistance application process on her behalf, presents an issue of immediate and irreparable harm to ManorCare, as an appeal of a denial of the application for Medical Assistance benefits filed on behalf of ORIGINAL ..' '. .. Defendant's mother will be denied absent the production of the necessary documentary evidence to determine Defendant mother's eligibility for Medical Assistance benefits. 4. The requested injunction would restore the parties to the status quo as it existed immediately prior to Defendant Gaylord Thompson's breach of the Agreement. 5. Greater injury would result from the denial of the requested injunction than from the granting of the same. a. Absent the injunction, without the documentation necessary to determine the eligibility of Defendant's mother for Medical Assistance benefits, the appeal of the denial of the Application for Medical Assistance benefits referenced above will be finally denied. b. No injury would result from the Defendant Gaylord Thompson's provision of the requested documents, required by his contractual obligations pursuant to the Agreement. 6. ManorCare's right to relief is clear. See Complaint, Exhibit II A.II 7. ManorCare lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Defendant Gaylord Thompson's mother has been financially unable to fully compensate ManorCare for the care and services that it has and will render to her in accordance with the terms and conditions of the Agreement. 8. A bond in the amount of $100.00 should be adequate in the event that it is later determined that the issuance of the instant petition was in error. 2 . ," '" '. WHEREFORE, Plaintiff ManorCare, respectfully requests that this Honorable Court schedule an immediate hearing on its request for injunctive relief, and thereafter issue a decree ordering specific performance of the Agreement by and between the parties hereto. Respectfully submitted, Dated: * By: SCHUT)fR BOGAR LLC _~U/~ Chadwick O. Bogar Attorney I.D. No. 83755 (717) 909-5920 Christal L. Hoo Attorney I.D. No. 90947 (717) 909-8640 305 N. Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff 3 . ... . CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Plaintiff's Petition for Preliminary Injunction was served via first-class, United States mail, postage prepaid, upon the following: Gaylord Thompson 2600 Wilson Parkway Harrisburg, PA 17104 Dated: ~o h By: ~ William Keslar Paralegal ..,.,- (J -n ::;:! rl1 :n ": 2j --i 0' ~ co "-4 'l~ (." ") :iJ r-..:> .< MANOR HEAL THCARE : CORP., d/b/a MANORCAREHEALTH: SERVICES - CARLISLE, : Plaintiff v. GAYLORD THOMPSON, : Defendant IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYL VANIA CIVIL ACTION - LAW NO. 06-5366 CIVIL TERM IN RE: PLAINTIFF'S PETITION FOR PRELIMINARY INJUNCTION ORDER OF COURT AND NOW, this 23rd day of October, 2006, upon consideration of the above motion, a hearing is scheduled for Wednesday, December 27, 2006, at I :30 p.m., in i Courtroom No. "Iv Cumberland County Courthouse, Carlisle, Pennsylvania. Chadwick O. Bogar, Esq. ~~stal L. Hoo, Esq. /,O? N. Front Street Suite 401 Harrisburg, P A 17101 Attorneys for Plaintiff Allord Thompson 2600 Wilson Parkway Harrisburg, P A 17104 Defendant, pro Se :rc BY THE COURT, .ci{ C" cr> C0 f( .c.C Yo Y~f~ .).~ 9--~ r\..\-...J- dl..L\ '..i- :c. \- tt5 ~ Ci- C"> c-J Y' ;.- '-oF .€/-- ~~), ",-r :~';:7: :';;'; -~ .--..,. ..." ,., ~ .:':~ ./ --. ;l~ .\~ .-,~ 1,.1...1 ':! 0... ~-- .v o ~ c;::;> i:-l :5 o - OCT 1 7200Sr IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/ a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. No. 06-5366 GAYLORD THOMPSON, Defendant. CIVIL ACTION - LAW/EQUITY ORDER tL And now, the ~ day of p~ e. 2006, the Court finds that ManorCare has established its right to a preliminary injunction: (1) The injunction is necessary to prevent immediate and irreparable harm to ManorCare that cannot be adequately compensated by damages; (2) Greater injury would result from refusing ManorCare's request for an injunction, and the issuance of an injunction will not substantially harm Defendant; (3) A preliminary injunction will properly restore the parties to their status quo as it existed immediately prior to Defendant's breach; (4) ManorCare's right to relief from Defendant's breach of the Agreement is clear; (5) The injunction ManorCare seeks is reasonably suited and limited in scope and breadth to abate the existing activity; and (6) The injunction is in the public's interest. ,11',;" ORIGINAL ;~ L7v ,,-?('. tjl nr'1, ~'\ 1:1 :?,J V\d ..)._\.I UI) ';'0 . _, rtr\ _..... It is ORDERED AND DECREED that Defendant is directed to cooperate with ~O~~ ManorCare's efforts to secure Medical Assistance benefits on Gay IVl J ' Thompson's behalf. The cooperation specifically includes immediately providing any and all financial records needed for the application and appeal process and taking any and all other actions necessary to obtain benefits. BY THE COURT: .;' J. . .. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 06-5366 AFFIDAVIT OF SERVICE Manor Healthcare Corp. d/bla Manorcare Health Services- Camp Hill vs. Gaylord Thompson / Commonwealth of Pennsylvania County of Dauphin SSe I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 11:34 AM on 01113/2007, I served Gaylord Thompson at 2600 Wilson Parkway, Harrisburg, PA 17104 in the manner described below: Ell o D o o o o Defendant(s) personally served. Adult family member with whom said Defendant(s) reside(s). Relationship is Adult in charge of Defendant(s) residence who refused to give name andlor relationship. Manager/Clerk of place of lodging in which Defendant(s) reside(s). Agent or person in charge of Defendant's office or usual place of business. an officer of said Defendant's company. Other: a true and correct copy of Order issued in the above captioned matter. Description: Sex: Male - Age: 38 - Skin: Black - Hair: Black - Height: 5' 10" - Wight: 165 ~ NOTAR1_P~!"~c ~TH OF PENNSYlVANIA NOTARIAl SEAL PAULA K. SMITH, Notary Public SUSQuehanna Twp., Oa\.~')hL~ Crd'.-+" , . Mv C!!rrwni~,~'rw' r'v~.'. . Law Firm:Schutjer Bogar LLC Address: 305 North Front Street, Suite 401, Harrisburg, PA, 17101 Telephone: (717) 909-5925 to and su scribed before me on this day of I 2cx:.Ll X J S nkowsky Invest' a 3 6 Fawn Ridge No t Harrisburg, PA 1 10 (800) 276-0202 Atty File#: 06-5366 - Our File# 417 ~W~TH OF PA' n.. NOTARIAL l:LNSYLVANIA s "'f.Jo\ K. SMITH USQuehanna li ,Notary Public My CommiSSion Wp". DalJphjn ~ &P;res Feb. 3, 2008 ORIGINAL ~---.---" - nr.: ,', -; '7 '),)0C: nr v __ .i J L~thi ~ l IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA MANOR HEALTHCARE CORP. d/b/a MANORCARE HEALTH SERVICES - CAMP HILL, Plaintiff, v. No. 06-5366 GA YLORD THOMPSON, Defendant, CIVIL ACTION - LA \V / EQUIn' ORDER 71) tt - And now, the ---L.-f-- day of 0~ Co 2006, the Court finds that ManorCare has established its right to a preliminary injunction: (1) The injunction is necessary to prevent immediate and irrep2rabIe harm to ManorCare that cannot be adequately compensated by damages; (2) Greater injury would result from refusing ManorCare's request for an injunction, and the issuance of an injunction will not substantially harm Defendant; (3) A preliminary injunction will properly restore the parties to their status quo as it existed immediately prior to Defendant's breach; (4) ManorCcne's right to relief from Defendant's breach of the Agreement is clear; (5) The injunction ManorCare seeks is reasonably suited and limited in scope and breadth to abate tIle existing activity; and (6) The injunction is in the public's interest. on#[NAL ""..:.<':,,,,_..,"--, __o_o.,~ ... _, __0"___ ~ 0,_ . It is ORDERED AND DECREED that Defendant is directed to cooperate with 12..0':::'2 ManorCare's efforts to secure Medical Assistance benefits on GdylulJ Thompson's behalf. The cooperation specifically includes immediately providing any and all financial records needed for the application and appeal process and taking any and all other actions necessary to obtain benefits. BY THE COURT: o ~ ""-"." ,';' ~ c:? c.:::> ~ <- "'\.':;;:l;jl :...~ --- N u.> s: - - ~ 1...,., rl1 f': -orrJ :. '.Q t? .I,() '~~:~~ -')' ~-\ 2p :.:<. o CJ"