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HomeMy WebLinkAbout02-2592HCR MANORCARE, 1NC., Plaintiff, Vo BONNIE J. RUSH and GARY D. RUSH, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION-LAW NOTICE You have been sued in court. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by an attorney and filing in writing with the court, your defenses or objections to the claims set forth against you. You are warned that if you fail to do so, the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER OR CANNOT AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Cumberland County Bar Association 2 Liberty Avenue Carlisle, Pennsylvania 17013 (717) 249-3166 SHERIFF'S RETURN - OUT OF COUNTY ~ASE NO: 2002-02592 p COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANORCARE INC VS RUSH BONNIE J ET AL R. Thomas Kline , Sheriff or Deputy Sheriff who being duly sworn according to law, says, that he made a diligent search and and inquiry for the within named DEFENDANT , to wit: RUSH GARY D but was unable to locate Him in his bailiwick. He therefore deputized the sheriff of YORK County, Pennsylvania, serve the within COMPLAINT & NOTICE to On June 19th , 2002 , this office was in receipt of the attached return from YORK Sheriff's Costs: Docketing 6.00 Out of County 9.00 Surcharge 10.00 Dep York Co 33.87 .00 58.87 06/19/2002 R. Thomas Kline l/j Sheriff of Cumberland County OBRIEN BARIC SCHERER Sworn and subscribed to before me this 2;~- day of ~ ~ao~ A.D. / ~ Prothonot~r~ SHERIFF'S RETURN - REGULAR 'CASE NO: 2002-02592 p COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANORCARE INC VS RUSH BONNIE J ET AL DOUGLAS DONSEN , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT & NOTICE was served upon RUSH BONNIE Jthe DEFENDANT , at 1325:00 HOURS, on the 3rd day of June , 2002 at 940 WALNUT BOTTOM ROAD CALRISLE, PA 17013 BONNIE J RUSH by handing to a true and attested copy of COMPLAINT & NOTICE together with and at the same time directing Her attention to the contents thereof. Sheriff,s Costs: Docketing 18.00 Service 3.45 Affidavit .00 Surcharge 10.00 .00 31.45 Sworn and Subscribed to before me this J/,~ day of Cl.,~ 3~21 A.D. ! /Prothonotar~ v 7 So Answers: R. Thomas Kline 06/19/2002 _~ z~ OBRIEN BARIC SCHERER /j// ~h_ ie/ epu~y Sheriff -~ /DeputyDouglasDonsen COUNTY OF YORK OFFICE OF THE SHERIFF 28 EAST MARKET ST., YORK, PA 17401 SERVICE CALL (717) 771-9601 SHERIFF SERVICE PROCESS RECEIPT -,nd AFFIDAVIT OF RETURN 1. PLAiNTIFF/S/ 3. DEFENDANT/S/ SERVE INSTRUCTIONS PLEASE TYPE ONLY UNE DO NOT BE'iACH ANY HCR ManorCare, Inc, 12. COURTNUMEER 02-2592 Gary D. Rush 14. TYPEOFWRITORCOMPLAINT Civil Complaint 5. NAME OF INDIVIDUAL, COMPAN~ CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY lO BE LEVIED ATTACHED OR SOLD, SE E OROESOR, T, ON O , , ~ =- r~uasan% view Terrace, New Cumberland, pA) 17070 AT 7.~. IN DI.._ICATE SERVICE: ~PERSONAL ~ PERSON IN CHARGE [~ DEPUTIZE -~-- I O 1ST CLASS MAiL O POSTED ~OTHER NOW.~ ~_, 20 0~2 . I, SHERIFF OF~ilI~ COUNTY, PA, do hereby deputize the s~f - · . . . COUNTY to execute thi ' e return there rding to law This deputmzatlon being made at the request and risk of the plaintiff. 8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: ADVANCE FEE PAID BY ATTY NOTE: ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy shedff levying upon or attaching any property under within writ may leave same without a watchman, in custody of whomever is found in possession, after notifyin person of levy or attachmen, wit liability on the pad of such deputy or the sher ff to any plaintiff herein for any loss, destruction, or removal of any properly before sheriff's sale thereof. , ~ / ~ 9. TYPE.NAMEan~ADDRESSofATTORNEY/ORIGINATORandSiGNATURE ' ~ 10. TELEPHONE NUMBER 11 DATEFILED 12. SEND NOTICE OF SERVICE COPY TO NAM.E AND ADDRESS BELOW: (This area must be completed if notice is to be mail Davld A. Baric, Esqulre ed). 17 Wes $~ACE BEOWFt~ Ilel: nc-rut= .u. .... C[~ERLAND COUNTY SHERIFF ................. ~e'aUl= UELOW FOR USE OF THE .-,.,- ............... - - fo. , ac~no~,e,ge recei of the wm' ~ LSHEFIIFF ~ DO NOT WRITE BELOW T pt -- IIUI W~lE I~ELOW THIS LINE or complaint as indicated above. J- ~UI~ZG I 14. DA~TE~R~E~C~ ~n/Headng Date lS. HOWSERVED: PERSONAL() RESIDENCE'-" ~-- ---- ----------------L--_ 5/30/02 I 6/29/02 ~ POSTED ( ) POE ( ) SHERIFF'S OFFICE ( ) 17~ (2~ ~~dividual, company, etc. name above. (See remsrks below.) OTHER (--!~I- SE~ REUARKS BELOW 21'/~ S ~//~~te Tl~e 'te~ (~')llot. Dal~ 41. AFFIRMED and subscribed iD before ~e th~ 1 ~. ~ ~ ~ ~ ~~ · Srgna ute ~ . I Notad~S~l 'I ...... [ ~' SignatumofYo~/ - ' . ] ~[ HCR MANORCARE, 1NC., Plaintiff, IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA v. : NO. 0.2. ,~5'q,2 ~ : BONNIE J. RUSH and : CIVIL ACTION-LAW GARY D. RUSH, : Defendants. : COMPLAINT NOW, comes Plaintiff, HCR ManorCare, Inc. ("Manor"), by and through its attorneys, O'BRIEN, BARIC & SCHERER, and files the within complaint and, in support thereof, sets forth the following: 1. HCR ManorCare, Inc. is an Ohio corporation, duly authorized to conduct business in the Commonwealth of Pennsylvania with an office located at 940 Walnut Bottom Road, Carlisle, Pennsylvania. 2. Defendant, Bonnie J. Rush, is an adult individual with a last known address of 940 Walnut Bottom Road, Carlisle, Pennsylvania. 3. Defendant, Gary D. Rush, is an adult individual with a last known address of 97 Pleasant View Terrace, New Cumberland, Pennsylvania. 4. ManorCare operates a skilled nursing facility located at 940 Walnut Bottom Road, Carlisle, Pennsylvania. 5. On or about January 11,2001, Bonnie J. Rush sought to be admitted to the Manor facility to obtain skilled nursing care. In connection with her admission to the facility, Gary D. Rush executed an Admission Agreement Contract Between Patient/Resident and Facility ("Admission Agreement") on behalf of Bonnie J. Rush. A tree and correct copy of the Admission Agreement is attached hereto as Exhibit "A" and is incorporated. 6. Gary D. Rush is the son of Bonnie J. Rush and he executed the Admission Agreement representing that he had a power of attorney to act on behalf of Bonnie J. Rush. 7. The Admission Agreement bound Bonnie J. Rush to pay for the costs of her care while a resident of the facility. 8. Bonnie J. Rush became a resident of the facility on or about January 12, 2001 and remains a resident to the date hereof. 9. On or about January 11,2001, Gary D. Rush completed and executed an Application for Residency seeking admission of Bonnie J. Rush to the facility. A tree and correct copy of the Application for Residency is attached hereto as Exhibit "B" and is incorporated. 10. Gary D. Rush represented on the Application for Residency that as of the time of completing the application, Bonnie J. Rush would be receiving social security benefits and other benefits totaling $1,682.00 per month. 1 I. The Admission Agreement bound Gary D. Rush to pay from the assets and income of Bonnie J. Rush, sums due for the costs of care not covered by a third party payor. 2 12. Upon information and belief, at all times since the admission of Bonnie J. Rush to the facility, Gary D. Rush has been receiving the social security benefits and other income of Bonnie J. Rush. 13. D.P.W. made a determination that Bonnie J. Rush was eligible for medical assistance and that Bonnie J. Rush was to pay a private portion from her income to ManorCare. D. P. W. set the private portion as being $1,866.00 per month. Despite demand therefore, neither Bonnie J. Rush nor Gary D. Rush has paid ManorCare for the costs of care accruing. 14. As of April 1, 2002, the sum of $21,394.30 remained due and owing for the costs of Bonnie J. Rush's care at the facility. 15. The Admission Agreement provides for the imposition of interest on past due balances at the rate of 18% per annum or 1.5% per month. Interest on the outstanding indebtedness to May 1, 2002 is $1,073.28 and continues to accrue at the rate of $9.60 per diem. 16. The Admission Agreement provides for the recovery of attorney fees incurred by ManorCare in the collection of a debt due and owing. COUNT I- BREACH OF CONTRACT HCR MANORCARE v. Bonnie J. Rush and Gary D. Rush 17. Plaintiff incorporates by reference paragraphs one through sixteen as though set forth at length. 18. All conditions precedent to recovery under the Admission Agreement have been met. 19. Gary D. Rush was obligated to use the assets and income of Bonnie J. Rush to satisfy the debt due and owing to ManorCare for services and care provided to Bonnie J. Rush by ManorCare. Further, Gary D. Rush agreed that he would take no action to dissipate any of the assets of Bonnie J. Rush which could be used to pay for the costs of her care at the ManorCare facility. 20. 21. Demand has been made upon Gary D. Rush to pay the outstanding debt. Gary D. Rush has, without justification, failed and refused to pay for the costs of care provided to Bonnie J. Rush. Bonnie J. Rush agreed to pay for the costs of her care at the facility. Demand has been made upon Bonnie J. Rush to pay for the costs of her care at the 22. 23. facility. 24. hercare. 25. Bonnie J. Rush has, without justification, failed and refused to pay for the costs of Bonnie J. Rush and Gary D. Rush have breached the Admission Agreement. WHEREFORE, Plaintiffmquests judgment in its favor and against the Defendants for the sum of $21,394.30 plus interest to the date of award, interest, costs, expenses and attorney fees and any additional sums due and owing to the date of award.. 4 26. length. 27. COUNT II- MONEY HAD AND RECEIVED HCR MANORCARE, INC. v. Gary D. Rush Plaintiff incorporates paragraphs one through twenty-six as though set forth at During the period of Bonnie J. Rush's residency at the facility, Gary D. Rush has received the social security benefits and other income payable to Bonnie J. Rush believed to be in the approximate sum of $23,822.50. 28. The proper use of these funds received by Gary D. Rush would have been to pay the costs accruing for the care of Bonnie J. Rush at the ManorCare facility. 29. At the time of receipt of these funds, Gary D. Rush knew that he was obligated to pay those funds over to ManorCare for the costs of Bonnie J. Rush's care at the facility. 30. Gary D. Rush gave no consideration for the funds of Bonnie J. Rush received by Gary D. Rush. 3 I. Demand has been made upon Gary D. Rush to tender the funds of Bonnie J. Rush to ManorCare which he has failed and refused to do. WHEREFORE, Plaintiff requests judgment in its favor and against Gary D. Rush requiring Gary D. Rush to: a) remm the subject matter in specie; b) pay over the value if Gary D. Rush has consumed the money in beneficial use; c) pay its value it Gary D. Rush has disposed of the funds received and d) award attorney fees, costs and expenses and interest. 5 32. length. 33. COUNT III- QUANTUM MERUIT HCR MANORCARE, INC. v. BONNIE J. RUSH Plaintiff incorporates paragraphs one through thirty-three as though set forth at Bonnie J. Rush used and enjoyed the services provided to her by ManorCare during the period of her residency at the ManorCare facility. 34. Bonnie J. Rush used and enjoyed these services provided to her by ManorCare without making payment for those services and she has been unjustly enriched thereby. WHEREFORE, Plaintiff requests judgmem in its favor and against Bonnie J. Rush for the value of the services rendered to him plus attorney fees, costs and expenses and interest. Respectfully submitted, David A. Baric, Esquire I.D. # 44853 17 West South Street Carlisle, PA 17013 (717) 249-6873 Attorney for Plaintiff dab.dir/m anor/rush/complaint.pid VERIFICATION I verify that the statements made in the foregoing Complaint are true and correct. I understand that false statements herein are made subject to the penalties of 18 Pa. C.S. § 4904, relating to unsworn falsification to authorities. DATED: Kimberly Etzler Business Office Manger HCR blanor Care ADblISSION AGREEMENT This Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of' providing for the rights and responsibilities or' the parties with respect to the Resident's stay at this HCR Manor Cure's Health Care Cen,er ( Cente ). Legal Representative: ~cYv~', ~ / I t /I Admission Date: _ I/'Qr~/O/ Deposit: S ,~l Term: This Agreement shall begin on the day the Resident enters the Center and end on, the day the Resident is discharged. RIGHTS AND RESPONSIBILITIES OF THE RESIDENT Board Rate. For the basic services provided for in Section 3.01, the Resident agrees to pay the appltcaole ~oom anu ~,~,~,~ The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room · 0~ and Board Rate set forth in Attachment A is payable in advance and is due by the tenth (1 ) day ot- each month. The Resident shall be responsible admission as well as the day of discharge. This Section shaI~ not apply it' the Resident is covered under a Governmental Program (see Section 1.05) or by a Third ?arty ?ayor or Managed Care Organization (see Section 1.05). ar. es The Resident further agrees to pay to the Center all charges for 1.02 ~' , ...... : .... r su,~,qies that may be requested by the additional medical, therapeutic, or personal care ~m Resident, ordered by the attending physician, or provided in the Restdent Plan of Care. The Center reserves the right to charge for personal care items of the Resident it' necessary for the well-being of the ResidenL 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 shall be included in the Resldent's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth (10t~) day of the month. EXA~IBIT "A" 1.03 ~. Accounts not paid in full within thlny (30) days ofbilling shall be subject to a sen,'ice charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 l~dependent Providers. The Resident shall be directb' responsible to independent providers, including but not limited to, the Resident's attending physician for an)' health or personal program in accordance xvith the terms o[the program. 0~ Governmental Pro,rams. If the Resident is eligible for~ coverage under any 1. ' ..... · -'-~ ---~- .... ~,he Veterans Administration, and governmental program, such as Medtcare, 5'teatcam, m m,.,,~,, · the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental, program(s) cease for any reason, the Resident will be charged at the Center's rate for private pa)' residents in accordance with Sections 1.0! and 1.02. The Center participates in the following programs: X Medicare, XMedicaid and/or. .VA. Medicare may pay for some or ali of the Resident's care. If Medicare agrees to pa)' 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 and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Iviedicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of' the Room and Board Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center ma)' take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Pavors and Managed Care 0manization~. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Orgamzation ( I-~MO ), preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"), or Physician Hospital Organization ("?HO'), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pa)' residents. Il'the Center has not executed a provider agreement with the Resident's third party payor, the Center liable for charges will bill the Restdent third party payor as a service, but the Resident remains not paid or covered by that thlrd party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident and/or Leg. al Representative acknowledge that they are respo~ble for paying the Center for items and services provided during the stay at the. Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly it' 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 Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resldent and/or Legal Representative agree to 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 and the Resident is not eligible for Medicaid, the Resident ,,,,'ill be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. · ion Information. It shall be the respons bility of the Resident and/or Legal · 1.0S dmisslm~ mtom~auon - .., ....... ,4,,a nformation regarding all third Representative to notify the Ce ~ter aha to provm= party payors or governmental coverages on admission and throughout the stay including copies insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center 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 and/or Legal Representative acknowledge that if they fail to provide such information, they 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. · ' n for Benefits. It shall be the responsibility of the Resident and/or Legal 1.09 A lication tot ~enems ....... ~-~:.*. on-i*,ilit,-, under any governmental, third Representative to apply for coverage ano to party payor, managed care or private insurance program. The Center shall be tinder no obligation to bill any third party payor other than the Legal Representative and, when applicable, .a governmental program third party payor or managed care organization with which the Center ~s under contract. · ' ilitv for Payment. Except for payments for.services covered 1.10 Erlma~ · ' ' ' Re~ponslb vider a ,reements, the Restdent shall remain primarily hable under governmental programs or pro g for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, I-[MO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors- This Agreement serves as a ~?itten notice, that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmen, tal payor, third party payor or managed care organization. The Resident and/or Legal Representatsve agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. 1.11 P._ersona Phvslclan. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the rules and policies of' the Center. At the tlme of' admission, the Resident must supply the Center with the name of bls/her personal physician. If the Resident changes physicians at any time aRer admission, the Resident and/or Legal Representative must immediately notify the Center of · · ' e. If the ohysi¢lan chosen by the Resident falls to provide needed the new phystc~an s nam ,.. ,%- ,- ..... Ii,-ohi aws and re~ulations, the Center shall have coverage and attendance or the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharn'~acy of choice, provided the pharmacy selected is properly licensed, packages and su. pplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSIBILITY OF THE LEGAL ILEPRESENTATIVE 2.01 ~. The Legal Representative hereby represents.that he/she has lega. l access to the Resideot's income or resources and that the documents supporting such authority, any, have been delivered to the Center. ke Pa merits t?n Behalf of Resident. The Legal Representative 2.02 ~greement to Ma ¥ ..... ,, c.~ and char~es for which the agrees to pay promptly from the Resldent's income or resources ,,, ,,-~o ~ incur personal Resident is liable under this Agreement. The Legal Representative shall not liability on behalf of the Resident except for a breach of the duty to pr?vide payment from the Resident's income or resources for the fees and charges provided for in thss Agreement. 2.03 ~ The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 E_,xhaustion of Resident'$ Funds.. If the Resident financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notiSy the Center in writing when the application for Medicaid is made. If the Legal and Representative fails to notify the Center m wnu g or fails to file for Medicaid in a timely proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been mad,.e in a timely and proper manner. 2.05 ~oooerati0n for Financial Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of'cooperation. 2.06 ~.cceptance Uoon Dischar~. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and p.~y for the dep.~rture or' the Resident from the Center. It' a~er notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means transportation and to deliver the Resident to the residence address of the Lega Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Responsibllities~ The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set for'th in this Agreement and Attachments. IlL RIGHTS AND RESPONSIBILITIES OF THE CENTER 3.01 Room and Standard Services~ As pan of the Room and Board Rate, the Center shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, sat-ely and general well-being ot- the Resident. 3.02 ~. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 ~ The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall 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 ['or advance payments shall be paid by the Center within thirty (30) days a~ter discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt ot- the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release ot- Informatio0_. The Resident and/or Legal Representative hereby consents to tile release ot- his/her medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third part)' payor or managed care organization responsible for ali or an)' party ot- the paym:ent or reimbursement ot- the Resident's charges, including any utilization review or quality assurance reviews or payment audits performed by such; the' perso'nnel of any hospital or other health care facility or provider to svhom or wNeh the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such ~nctions, 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 dally activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resldent's personal physician in the Resident's ?lan of Care, or as required from time to time in the exercise of good nursing iudgment, Subiect to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, .,nd that such Legal Representative hereby consents on behalt'of the Resident to the Treatment described above. 4.03 Consent to Photo~_raoh. The Resident and/or Legal Representative agree to consent to the Center taking a photograph of Resident for use in identi~'ing 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 staffto identi~' the Resident. 4.0:1 Notice of Services, Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have b~en explained and have received copies of the items or policies and procedures, if applicable. Tile Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of Medical Information. See Attachment C. Authorization for Payment of Benefits. See Attachment D. Social SecurRy Administration Appointment. See Attachment E. SNI: Ivtedicare Determination Notice. See Attachment F. Medicare Sccondary Payor Questionnaire. Sec Attachment G. At the request of the Resident and/or Legal Representative, the Center shall maintain tile Resident's personal funds in compliance wRh tile laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident ~unds and the Personal Trust Fund Agreement, Resident Personal Fuhds and the Personal Trust Fund Agreement, Resident Personal Funds Authorizatlon and any other rehtted documents. See Attachment H-I and The Center's policy and procedure on bedholds, election of' bedholds and readmlsslon. See Attachment I (Center Supplement). Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). Name, address and phone number 6f Ombudsman. See Attachment I (Center Supplement). The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement!. Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. See Attachment I (Center Supplement). The Resident Handbook. See Attachment J. Resident/Patient Rights. See Attachment K. Medicare/Medicaid information and display of such information including how to apply for and use Medicare and btedicaid benefits, and how to receive refunds for previous payments. See Attachment L. Receipt of int'ormation on advance directives including a copy or' "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Cafe's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of' its laws governing the Resident's right to direct his/her medical treatment. See Attachment M-1 and M-2. Privacy Act Notification. See Attachment N. V. W. X. y. Z. Inventory sheet and/or policy of personal items. See Attachment O. ASM Form. See attachment ?. pM1::Lt~.lOi~t.~, v~CCTNF, COMS~IT FORM See Attachment Q. See Attachment R. See Attachment S. See Attachment T. See Attachment U. See Attachment V. See Attachment W. .05 A~sienment of BenefitS. The Resident and/or Legal Representative hereby that pa~,ment of authorized government and/or third party payor benefits as described in 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to n my behalf for any service furnished by or in the Center. The Resident and/or Legal ntative hereby authorizes the Center and any holder of medical or other information to such information to the Health Care Financing Administration and its agents and to thlrd .yors any information needed to determine these benefits or benefits for related services. 4.06 Termination, Discharge and Transfer. Th~s Agreeme~ mr, t flow an~ as set for'th in the Resident Handbook under the Se g ' sident and/or Legal Representative may terminate this Agreement before the Resident's ge from the Center by providing the Center written notice of the Resident's desire to leave seven (7) days in advance of the Resldent's departure. If the Resident leaves before the that time, the Resident must still pay for each day of the required notice unless the Center : bed before the end of the notice period. Except in the event of an emergency or death, the at shall be responsible for all charges for the Room and Board Rate and for all services ned up to the end of the day that the Admission ends. Discharge from the specialized units ; the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. barge or transfer becomes necessary because the Resident and/or Legal Representative or ne else abused the Resident's funds, the Center will request that local, state and federal · ities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification% The Resident shall defend, indemnify and hold the Center ess from any and all claims, demands, suit and actions made against the Center by any -~ resulting from any damage or injury caused by the Resident to any person or the pr6perty of any person or entity (including the Center), except in the case of negligence of the Center's employees and agents. 4.08 Chan~es in the Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center ~vill continue to fulfill their respective obligations under this Agreement consment x tth the la~v. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREE5'IENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION, Date: Signature of Resident: Sign~tu/se o~'Legal Repr~s~tative, if signing on behalf of Resident: Signature of Legal Representative, signing on his/her own behalf: Date: _ To ap~ly for adm!ss,gn .to. our Nurs,ng Center, please mmplete the follow, ng quesbonnai~ig;[~ return it to the Admissions Office.~is ~pplimtion will become a'pad of the 'Adm ~hould bo complotod m h~sto~ ~d physi~l examination results will be recorded on another document. Name of Prospe~ive ResidenvPatient. Date of Bi,h: Address. ~3 ~ ~ '~ Telephone N~D~'~, Marital Status: If Married orWidowe0, Nameof Spouse: ~' C. ~*~ Social Securi~ No.: Insumnco is: ~ Pdma~ ~ 8oconda~ ~ Co-in~uranco Name of Inquirer: - ~ ~.' ~5~ nelationship~ :~o~ (line2) ~ ~~, P~ ~ otherPh;~eNo.:(~q~-O~0(~ ~her persons to conta~ Name ~: Addre~: (line2) How did you hear ~bout ' ~ ~ Numing . O'Physician . O Othe[,~um~ng Center . ~ Assisted Living Cente?t2.~ ;~;~,- ':.Y~. Havo you v~t~d, ~ny other Nursing Oentem Or Assisted Uving ~ciliti~ y,s Mother's Maiden Name: ~.12.~ .. Placeof aiflh:Ci~ :~0~" : ' Coun~ :'~ : :' 'Stat~' Pmf, rrod ~mbulaneo Company (optional): ~amo ~o~ '. ' ' ~' ' '..~ Current Prima~ Physician:' ~f. '~- ~w~ ~¢ : To ephone No; ' - : Phys c an to Fo ow at Fac ~ ~. ~ ~ ~ Tell us about the ResidenVPatient~ (pleaSe Check all that apply)' O Slightly ~orge~ul : Q Walks with a~sistance Q Confused . ~ Continent :~ncontinent . . ~ '~. Admi~ion desired on: ~-I~- O~ · .. ,~.. : , , If . Admi~edfrom ; Where has the residenFP~ti~nt lived in the last 60 da~s~ ~.5~ The facili~ requires that a source Of Payment be identified to pay for the ResidenFPati~t's ~a~e. A pemon, other than the resident, may wish to be financially responsible fo~ the 'cos~ ~of' the ~re ("guarantor). The facili~ does not require a ~guaranto~. ~ Has a ~owor of ~OrnOybO~ ~on[~rSd 0n [ho p,rSo~(s) to Has a egal guar ~e~,~,a~.,eu uy a No Has a Burial Trust been' established? .... If no, who ~, the pro[,rred funoral so,mo for To process your apP!!c~ti~n; the. folfowing informatio.n is required. The infOrmatiOn ~Uppli~di~nfid~ti~i and allows us to .ass~st'y0u in'Your long,term Planning; The financial' data:Should !l~e'~th~t"~f"th~ Resident/Patient and or the~ Guarantor. All income and ~mou~nts listed Whether li~ted under,h6 or Guarantor column, must e~ther be owned by the Res dent or ~n fact be avmlable to the Resident for the Res'dents staY'at the fac' 'ty. Your cooperaron is appreciated 'n order to exped:te Please note that it is not mandated that a Resident have a Guarantor, 0nly that a Source identified. Thus, any person' who agrees to be a Guarantor is doing so VOluntarily.. Cash $ . $ ' Checking -7~oo~ .. Savings Money-Market Certificates of Deposit Securities (Stocks/BondS). Trust Annuities (if not yet paying monthly) Salary . $ Social Security : ' Pensions/Annuities (if not above) IRA (if not above) · Interest/Dividend Income Rental Income Trust investments/Other Long-Term Care Insurance . "' · - ', Property: ' · Name on Dee~Title' * · '- Property:. · : Name on Deed/Title - Cash Value Life InSum Vested Pension Benafi Bus~ness Interests / Automobiles ,.;~ ;; ~.;! ~; ~,'~:~ Home Mortgage ,:-:,-,>..., .;~, Credit Cards/Charge Accounts Loans "~-; Other Debts · Taxes Owed Total Liabilities: NET WORTH: (Assets - Liabilities) ?2:: PLEASE SIGN BELOW: ....... . .... - ~., I hereby, warrant. *and represent that the information provided i~ accurate and complete." I '':under-{and' * ~* ' : that the nursidg facility will rely upon the accuracy and completeness of the above financial information in making an admission decision, I also understand that if any of the nformation is not accurate or not complete, the Facility will have detrimentallY relied uPon 'the above financial information and will suffer financial loss and harm. The assets listed are in fact available to the Resident to pay for the Resident's care· - ~- Guarantor's Signature Reviewed by:. '· ' '- Admissions Director's $i~natura Date HCR MANOR CARE, INC. Plaintiff V, BONNIE J. RUSH & GARY D. RUSH Defendants IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA NO. 02-2592 CIVIL ACTION - LAW PRAECIPE FOR ENTRY OF APPEARANCE To: THE PROTHONOTARY OF CUMBERLAND COUNTY PLEASE NOTE that, pursuant to PA. R.C.P. No. 1012, The Law Offices of Markian R. Slobodian, appears for Bonnie J. & Gary D. Rush, Defendants in the above-referenced case. Respectfully submitted, Dated: ~/~ THE LAW OFFICES OF MARKIAN R. SLOBODIAN I.D. NO. ~107~qL~BOOIAN' ESQ. ANDREW R. EISEMANN, ESQ. I.D. NO. 87441 801 North Second Street Harrisburg, PA 17102 717/232-5180 Attorneys for Defendants CERTIFICATE OF SERVICE I, hereby certify that I have, this date, served a true and correct copy of the foregoing Praecipe by U.S. Mail, first class, postage prepaid, addressed to the following individual: David A. Baric, Esq. O'Brien, Baric & Scherer 17 West South Street Carlisle, PA 17013 E' SQ. Dated: HCR MANORCARE, INC., Plaintiff, Vo BONNIE J. RUSH and GARY D. RUSH, Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA NO. 2002-2592 CIVIL TERM CIVIL ACTION-LAW PRAECIPE TO DISCONTINUE TO THE PROTHONOTARY: Kindly mark the above-captioned action as having been settled and discontinued without prejudice. Respectfully submitted, David A. Baric, Esquire I.D. # 44853 17 West South Street Carlisle, Pennsylvania 17013 (717) 249-6873 CERTIFICATE OF SERVICE I hereby certify that on October 9, 2002, I, David A. Baric, Esquire of O'Brien, Baric & Scherer, did serve a copy of the Praecipe To Discontinue, by first class U.S. mail, postage prepaid, to the party listed below, as follows: Andrew R. Eisemann, Esquire Law Offices Of Markian R. Slobodian 801 North Second Street Harrisburg, Pennsylvania 17102 /~ David A. Baric, Esquire