HomeMy WebLinkAbout06-6208HCR MANORCARE, INC., IN THE COURT OF COMMON PLEAS OF
Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA
V. NO. 2006- 6 a pg
CHRISTOPHER A. HINDS and CIVIL ACTION-LAW
LORI HINDS, husband and wife,
Defendants
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Cumberland County Bar Association
32 South Bedford Street
Carlisle, Pennsylvania 17013
(717) 249-3166
HCR MANORCARE, INC., IN THE COURT OF COMMON PLEAS OF
Plaintiff CUMBERLAND COUNTY, PENNSYLVANIA
V. NO. 2006-
CHRISTOPHER A. HINDS and CIVIL ACTION-LAW
LORI HINDS, husband and wife,
Defendants
COMPLAINT
NOW, comes Plaintiff, HCR ManorCare, Inc., ("ManorCare"), 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.
2. Defendant, Christopher A. Hinds, is an adult individual with a last known address
of 39 Larch Drive, Shippensburg, Cumberland County, Pennsylvania 17257.
3. Defendant, Lori Hinds, is an adult individual with a last known address of 39
Larch Drive, Shippensburg, Cumberland County, Pennsylvania 17257 and is the spouse of
Christopher A. Hinds.
4. ManorCare operates a resident nursing facility located at 1070 Stouffer Avenue,
Chambersburg, Franklin County, Pennsylvania ("facility") 17201.
5. On or about June 25, 2004, Robert N. and Hazel S. Hinds became residents of the
facility. In connection with this admission, Hazel S. Hinds executed an Admission Agreement
for her admission to the facility and signed the Admission Agreement for Robert N. Hinds as his
Responsible Party. True and correct copies of these Admission Agreements are attached hereto
as collective Exhibit "A" and are incorporated by reference.
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5. On or about July 8, 2004, Christopher A. Hinds became the attorney-in-fact for
Hazel S. Hinds, his mother, pursuant to a Power of Attorney a true and correct copy of which is
attached hereto as Exhibit "B" and is incorporated by reference.
6. The Power of Attorney gave Christopher A. Hinds the right to control accounts at
M&T Bank in which Hazel S. Hinds was an account holder.
7. In the summer of 2004, both Hazel S. Hinds and Robert N. Hinds made
application for Medical Assistance to pay the costs of care accruing at the facility.
8. Upon information and belief, at all times relevant hereto, Christopher S. and Lori
Hinds have been receiving social security and pension benefit income of Robert N. and Hazel S.
Hinds.
9. The Department of Public Welfare, Franklin County Assistance Office approved
medical assistance benefits for both Hazel S. Hinds and Robert N. Hinds in July of 2004. In
connection therewith, the Department established a monthly "private pay" portion which Hazel
S. and Robert N. Hinds were to pay to the facility from their respective monthly incomes.
10. Hazel S. and Robert N. Hinds have failed and refused to remit the private pay
portion for the costs of their care. As of the date of this complaint, there is due and owing to
ManorCare the sum of $5,915.24 for the account of Robert N. Hinds and $1,406.39 for the
account of Hazel S. Hinds.
11. Christopher A. and Lori Hinds were notified and aware of the monthly private pay
obligation as established by the Department of Public Welfare.
U
COUNT I-MONEY HAD AND RECEIVED
HCR ManorCare, Inc. v. Christopher A. Hinds and Lori Hinds
12. Plaintiff incorporates by reference paragraphs one through eleven (11) as though
set forth at length.
13. During the period of the residency of Robert N. and Hazel S. Hinds at the facility,
Christopher A. and Lori Hinds have received the sum of at least $50,000.00 in income of Robert
N. and Hazel S. Hinds.
14. During the period of the residency of Robert N. and Hazel S. Hinds at the facility,
Christopher A. and Lori Hinds received the sum of at least $73,000.00 from the proceeds of sale
for the residence of Robert N. and Hazel S. Hinds located at 8485 Newburg Road, Newburg,
Franklin County, Pennsylvania.
15. The proper use of the funds so received by Christopher A. and Lori Hinds would
have been to pay the costs accruing for the care of Robert N. and Hazel S. Hinds at the facility.
16. At the time of receipt of these funds, Christopher A. and Lori Hinds knew they
were obligated to pay these funds over to ManorCare for the costs of care for Robert N. and
Hazel S. Hinds at the facility.
17. Christopher A. and Lori Hinds gave no consideration for the funds of Robert N.
and Hazel S. Hinds so received.
18. Demand has been made upon Christopher A. and Lori Hinds to tender the funds
of Robert N. and Hazel S. Hinds to ManorCare and they have refused to do so.
IL'
WHEREFORE, Plaintiff requests judgment in its favor and against Christopher A. Hinds
and Lori Hinds requiring them to:
a) return the subject matter in specie;
b) pay over the value if they have consumed the money in beneficial use; or
c) pay its value if they have disposed of the funds received and
d) award attorney fees, costs, expenses and interest.
COUNT II-CONVERSION
HCR ManorCare, Inc. v. Christopher A. Hinds and Lori Hinds
19. Plaintiff incorporates by reference paragraphs one through eighteen (18) as though
set forth at length.
20. At the time Christopher A. and Lori Hinds received the funds of Robert N. and
Hazel S. Hinds, Christopher A. and Lori Hinds were aware they had a legal obligation to dispose
of those funds to or for the benefit of Robert N. and Hazel S. Hinds and to pay ManorCare the
private pay portion of the debt accruing for the care of Robert and Hazel S. Hinds.
21. Knowing they had the aforesaid obligation, Christopher A. and Lori Hinds
appropriated funds of Robert N. and Hazel S. Hinds to their own use and benefit.
22. Christopher A. and Lori Hinds have intentionally and substantially interfered with
ManorCare's right to receive the funds of Robert N. and Hazel S. Hinds for payment of the
amount due and owing.
WHEREFORE, Plaintiff demands judgment against Christopher A. Hinds and Lori Hinds
for the sum of $7,321.63 plus any additional amounts coming due to the date of award, expenses,
costs, attorney fees and punitive damages.
Respectfully submitted,
O' N, BARIC H
6 David A. Baric, Esquire
I.D. 44853
19 West South Street
Carlisle, Pennsylvania 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/manorcare/hinds/complaint.pld
10/11/2006 14:36
7172495755
CBS
PAGE 09
VE)(t UCA-TION
The statements in the foregoing Complaint are based upon information which has been
assembled by my attorney in this litigation. The language of the statements is not my own. I
have read the statements; and to the extent that they are based upon information which I have
given to my counsel, they are true and correct to the best of my knowledge, information and
belief. I understand that false statements herein are made subject to the penalties of 18 Pa.C.S. §
4904 relating to unsworn falsifications to authorities.
DATE: t Gl%'
OCT 11 2006 16:04
7172495755 PAGE-09
A.
HCR Manor Care
Pennsylvania
ADNIISSION AGREEMENT
This Agreement is entered into by and among HCR ManorCare-Chambersburg, 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 respect to the
Resident's stay at this HCR Manor Care's Center ("Center").
Center: HCR ManorCare-Chambersbura
Resident: Robert N. Hinds
Responsible Party: QbxA! ds q(Utl S nd
Admission Date: 06/25/2004 Deposit: $
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.
1. RIGHTS AND RESPONSIBILITIES 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 as well as the day
of discharge. This Section will not apply if the Resident is covered under a governmental
program (see Section 1.05) 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
succeeding month, and are payable in full, along with the Room and Board Rate upon receipt.
EXHIBIT "A"
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1.03 Collections/Late Payments. Payment is due in full within thirty (30) days of
billing. Should the Resident's account for any reason be turned over for collection, the Resident
will pay the Center's collection costs, including attorney's fees.
1.04 Independent Providers. The Resident is directly responsible to 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 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 pay residents in accordance with Sections 1.01 and 1.02.
The Center participates in the following programs: 'V4edicare, Medicaid and/or VA.
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 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. The Resident and/or Responsible
Party are responsible for applying for Medicaid. 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 agrees 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 fails to pay the contribution amount, the
Center may take such legal action as necessary, including requesting a court to order such
payment.
1.06 Third Party Payors and Managed Care Organizations. If a Resident is a
participant in a plan offered by a third party payor such as a Health Maintenance Organization
("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"),
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 applicable
agreement. The Resident 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
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will bill the Resident's third party payor as a service, but the Resident remains liable 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 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 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
and/or 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-payment in accordance with this Agreement, Resident Handbook
and state and federal laws.
1.08 Admission Information. 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 verification 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 the Resident fails to provide such information, the Resident may be
responsible for zany 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, managed 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 Primary Responsibility for Payment. Except 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,
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 written notice that the Center has notified the
Resident and/or Responsible Party that services provided at the Center may not be covered by a
governmental payor, third party payor or managed care organization. The Resident and/or
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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.
1.11 Personal Physician. The Resident has the right to choose a personal 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 name of his/her 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 needed coverage and
attendance or fails to abide by applicable laws and regulations, the Center will 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 medication distribution system similar to the Center's ancillary pharmacy's medication
distribution system.
U. RIGHTS AND RESPONSIBILITY OF THE RESPONSIBLE PARTY
2.01 Legal Authority. The Responsible Party represents that he/she has legal access to
the Resident's income or resources and that the documents supporting such authority, if any,
have been delivered to the Center.
2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will
pay promptly 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 financial
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 for any services
or products specifically requested by the Responsible Parry to be supplied to the Resident, unless
such services or products are covered by a governmental program.
2.04 Exhaustion 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
for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In
addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid
in a timely and proper manner, the Responsible Party will be personally liable for all charges and
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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 for 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
Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable
notice for nonpayment, as provided in Section 4.06.
2.06 Acceptance Upon Discharge. 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 requested, 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 purposes of
avoiding the Responsible Party's obligation to make payments on behalf of the Resident under
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.
III. RIGHTS AND RESPONSIBILITIES 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 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, safety and general well-being of the
Resident.
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3.02 Other Services. The Center will act in accordance with the Resident Handbook,
which is incorporated by reference in this Agreement.
3.03 Deposit. The Center acknowledges receipt of the Deposit, if any, noted at the
beginning of this Agreement. The Deposit will 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 law. In the case of Medicaid Residents, any such refund will be paid within thirty (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 of Information. 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 parry 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 or 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 Consent to Treat. The Resident and/or Responsible Party 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 documents
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 Photo rg gh. 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.
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e
4.04 Notice of Services Policies 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, if applicable. The Resident and/or
Responsible 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
and/or 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-1 and F-2.
e. Center Supplement:
1. Policy and procedure on bedholds, election of bedholds 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 unit.
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 certification agency
concerning resident abuse, neglect, mistreatment and
misappropriation of property.
f. The Resident Handbook.
g. Resident/Patient Rights.
h. Medicare/Medicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
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receive refunds for previous payments.
i. Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR 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-1 and G-2.
Privacy Act Notification. See Attachment H.
k. Notice of Information Practices and Receipt of Notice of Information
Practices. See Attachments I-1 and I-2.
1. Ancillary Services Management Form. See Attachment J.
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 and/or
Responsible Party authorize the Center and any holder of medical or other information to release
such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and
to third party payors any information needed to determine these benefits or benefits for related
services.
4.06 Termination. Discharge 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 of the 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 the 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.
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4.08 Changes in the Law. Any provision of this 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 will continue to fulfill their respective obligations under this Agreement consistent with
the law.
THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE
EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT
THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY
QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION.
Signature of Resident: Date:
Signature of Responsible Party: Date:
- As- 6q
Center Representative: Date: -cis -o
ATTACHMENT A
ROOM AND BOARD RATE
The Resident will pay the following monthly rate:
Semi-Private Room:
a
3-Bed Room:
Subacute Semi-Private Room:
3-Bed Room:
Private Room:
4-Bed Room:
Subacute Private Room:
4-Bed Room:
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ATTACHMENT B
ANCILLARY CHARGES
The services and supplies categorically described on this Attachment are not included in the
basic Room and Board Rate. Therefore, the Resident will be individually billed for these items in
accordance with Section 1.02 of the Admission Agreement. A complete list of ancillary items,
together with the current price, is on file at the Center's business office.
Personal laundry and dry cleaning.
Personal care items, such as toothbrush, toothpaste, mouthwash, deodorant, hairbrush, Efferdent,
tissues, razors, etc.
Beauty and Barber Shop services
Tobacco and smoking supplies, newspapers and periodicals
Stationary, postage, and writing implements
Radios, televisions, cable service, room telephone
Transportation for non-medical purposes and ambulance charges
Photocopies of medical records
Personal physicians and specialists
Dental services and Dentures
Optometrist/Ophthalmologist services and Eyeglasses
Podiatry services
Special nursing services, such as hand feeding, and care for catheters, decubiti, incontinence,
isolation and dressings
Therapy services, including physical, speech, occupational, audiology and respiratory therapy
Prescription and non-prescription medication
Laboratory and x-ray tests
Oxygen and ielated supplies
IV Therapy and supplies
Peritoneal dialysis
Tracheotomy supplies
Ventilator rental and related supplies
Medical supplies, including but not limited to syringes, dressings, catheters, colostomy bags, tubes,
surgical stockings, and all other supplies necessary for the treatment, nursing care, or well-
being of the Resident
Incontinence supplies
Special equipment (for some items, a rental, rather than purchase fee is charged), such as
wheelchairs, wheelchair pad, trapeze, canes, geri-chair, special mattresses, porta-chairs, etc.
Special, supplementary, or very low calorie prescription dietary products, including liquid for gastric
and naso-gastric tubes, and any supply necessary to accomplish special feedings.
12
ATTACHMENT C
ASSIGNMENT FOR PAYMENT OF BENEFITS
RESIDENT'S NAME: Hinds. Robert N
SOC. SEC. NUMBER: 186-24-7694
MEDICARE NUMBER:
ADMISSION DATE: 06/25/2004
1, Hinds, Robert N, authorize my insurance company, third party payer or
governmental payer to pay HCR ManorCare-Chambersburg directly for healthcare services
rendered to me or my named dependent identified below and assign the right to receive
payment of those benefits to the Center.
I also consent to the use and disclosure of my and my named dependent's protected
health information for purposes of obtaining payment for healthcare services provided to me
or my named dependent.
I understajid that this assignment applies to those eligible charges for which I am
covered by my insurance company's benefit or third party payer and that any additional
and/or denied charges are entirely payable by me.
A copy of this will serve as an original.
Signature of Resident Date
-41
nztz "a
And/Or R ponsible Party Date
(Copies to Resident/Responsible Party and Center.)
Resident Name: Hinds, Robert N Medical Record Number: 22476
13
ATTACHMENT D
HCR Manor Care
SKILLED NURSING FACILITY DETERMINATION
SNF NamJ : H n -Chamberstw
DATE: jaj
T0: Name: Chris Hinds
Address: 39 Larch Drive
City, State, Zip: Shiooensbura. PA 17257
RE: Beneficiary Robert N. Hinds
Admission Date: 0612512004
Medicare Number (HIC#):
On 1o k&R V`t , we reviewed your medical information available at the time of, or prior to admission, and we believe that the service(s)
beneficiary name) needed did not meet the requirements for coverage under Medicare. The reason is:
ou had no 3 day hospital qualifying stay
You have previously exhausted your 100 Medicare days coverage
? You are not entitled to Medicare Part A
? Your discharge from the hospitaVSNF has exceeded 30 days
T! If the resident is waiving Medicare benefits complete the "Voluntary Waiver of Medicare Benefits' Letter'
II. ADMISSION or CONTINUED STAY - SKILLED CARE DENIAL
n Facility Decision n Utilization Review Committee Decision
On 1 I , we reviewed your medical information and found that the services furnished (you)
qualified as covered under Medicare beginning I I The reason is:
? You have used the full 100 days of Medicare coverage allowed under the Medicare program for Skilled Nursing facility coverage.
no longer
? Medicare covers medically necessary skilled nursing care needed on a daily basis. You only needed oral medications, assistance with you daily
activities and general supportive services. There is no evidence of medical complications or other medical reasons that required the skills of a
professional nurse or therapist to safely and effectively cant' out your plan of care. Therefore, we believe that your care cannot be covered under
Medicare.
? Medicare covers medically necessary skilled care needed on a daily basis. You only needed . This does not require the
skills of a licensed nurse to perform the service or to manage your care. Since you needed neither skilled nursing nor skilled rehabilitation on a dairy
basis, we,betieve your stay is riot covered under Medicare.
? Medicare covers medically necessary skilled care needed on a daily basis. You only needed after 1 1
Since you no longer require skilled nursing and did not need skilled rehabilitation on a daily basis, we believe your stay beginning I / is not
covered under Medicare.
? Medicare covers medically necessary skilled care needed on a daily basis. You needed skilled nursing care beginning I / to observe and
evaluate your condition. There is no indication of further likelihood of significant changes in your care plan or of acute changes or complication in your
condition. Since you no longer need skilled nursing or skilled rehabilitation services on a dairy basis, we believe your stay after ! ! is not
covered under Medicare.
? Medicare covers medically necessary skilled care needed on a daily basis. Because of your condition you needed a skilled nurse from / /
through / I to evaluate and manage your care plan. Your condition has improved so the services you need can safely and effectively be
given by non skilled persons. Since you no longer require skilled nursing and did not need skilled rehabilitation services on a daily basis, we believe
your stay is not covered under Medicare after / /
? Medicare covers medical necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time
where progressive learning is demonstrated. You have learned to perform the tasks ordered by your physician by / / but the therapist
continued services. Since you did not need skilled services after that date, we believe your stay is not covered under Medicare beginning
? Medicare covers medical necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time
where progressive teaming is demonstrated. You needed only to be reminded to follow the physician's instructions. This does not require the skills of
a professional nurse or therapist. Therefore, we believe that this service is not covered under Medicare.
? Medicare covers medically necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time
where progressive learning is demonstrated. You received teaching and training for a reasonable time but demonstrated you were not able, at this
time, to learn or make progress to perform the activities ordered by your physician. Therefore, we believe that skilled services are not covered under
Medicare after I I
15
? Medicare covers daily skilled nursing care related to the insertion, sterile irrigation and replacement of urethral catheter if the use of the catheter is
reasonable and necessary for the active treatment of a disease of the urinary tract or for patients with special medical needs. Skilled nursing is not .
considered medically necessary when urethral catheters are used only for mere convenience or the control of incontinence. Since your catheter was
inserted for convenience or the control of your incontinence. We believe that your care is not covered under Medicare.
Medicare covers medically necessary skilled rehabilitation services. The medical information shows that the only therapy services you needed
beginning / _/were repetitive exercises and help with walking. These do not generally require the skills or the supervision of a qualified
therapist. There was no evidence of medical complications which would have required that services be performed by a qualified therapist. We
believe therapy services are not covered under Medicare after I I
? Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis. The therapy services you received were for your
overall fitness and general well-being. They did not require the skills of a qualified therapist to perform and 1 or to
supervise the services. Since you did not need skilled nursing or skilled rehabilitation services , we believe your stay is not covered under Medicare.
? Medicare covers medically necessary skilled rehabilitation services to establish a safe and effective program to maintain your functional abilities, This
program was established and beginning 1 1 , the therapy services you received were to carry out this program. These
services do not require the supervision or skills of a therapist and, therefore, we believe that the services are noU would not be
covered under Medicare.
? Medicare covers medically and necessary skilled care when needed on a daily basis. The (specify services) you
received istare considered a skilled service by Medicare. However based on the medical information provided, this/these services(s) is not/are not
considered a specific and /or effective treatment for your condition. Since the services(s) you received was not/were not reasonable or necessary for
the treatment of your condition, we believe your stay is not covered under Medicare.
? Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis. The therapy services
provided was not/were not reasonable in relation to the expected improvement in your condition. In this case, since you do not need skilled nursing on
a daily basis and the therapy services are not considered reasonable and necessary, we believe, your stay is not covered under Medicare.
? Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis. While you required skilled
from I I to / 1 , the medical information shows that the therapy services after that time are not
reasonable in relation to the expected improvement in your condition. In this case, since you do not need skilled nursing on a daily basis and the
therapy services are not considered reasonable and necessary, we believe, your stay after I I is not covered under Medicare.
? Medicare covers medically necessary skilled care when needed on a daily basis. Although (service) generally requires the
skills of a the frequency with which the service is given must be in accordance with accepted standards of medical
practice. The service(s) you received is notlare not normally needed on a daily basis. The medical information does not stow medical complications which
require the services to be performed on a daily basis, In this case, the services are not considered reasonable and necessary. Since you did not need skilled
nursing or skilled rehabilitation on a daily basis, we believe your stay is not covered under Medicare.
This decision has not been made by Medicare. It represents p our (or) p the Utilization Review Committee's judgment that the services you needed did not meet or no
longer met Medicare' payment requirements. A bill will be sent to Medicare for services you received before / / . Normally, the bill submitted to Medicare does
not include services provided after this date. If you want to appeal this decision, you must request that the bill submitted to Medicare include the services we determined
to be non-covered. Medicare will notify you of its determination. If you disagree with that determination you may file an appeal.
7c We are placing you in a part of this facility which is not appropriately certified by Medicare because you do not require a level of care that will qualify as skilled nursing
care. Nonqualifying services furnished a patient in a non•cerfified or in appropriately certified bed are not payable by Medicare. .
Under a provision of the Medicare law, you do not have to pay for non-covered services determined to be custodial care or not reasonable and necessary unless you
had reason to know the services were non-covered. You are considered to know that these services were non- covered effective with the date of this notice. If you have
questions concerning your liability for payment for services you received prior to the date of this notice, you must request that a bill b e submitted to Medicare. We regret
that this may be your first notice of the non-coverage of services under Medicare. Our efforts to contact you earlier in person or by telephone were unsuccessful. Please
check one of the boxes below to indicate whether or not you want your bill submitted to Medicare and sign the notice to verify receipt.
Sincerely yours,
Signature of Administrative Officer
16
V. REQUEST FOR MEDICARE INTERMEDIARY REVIEW
? A. I do want my bill for services 1 continue to receive to be submitted to the intermediary for a Medicare decision. You will be informed
when the bill is submitted. If you do not receive a formal Notice of Medicare Determination within 90 days of this request you should
contact:
• AdminaStar Federal
• CareFirst (Blue Cross of Maryland)
n
80 W. 8th St.
1946 Greenspring Dr
Cincinnati. 0. 45203
Timonium, Md. 21093
Name and Address of Intermediary
? B. I do not want my bill for services I continue to need to be submitted to the Intermediary for a Medicare decision. I understand that I do not
have Medicare rights N a bill is not submitted. Note: Beginning October 1, 1989, you are not required to pay for services which could be
covered by Medicare until a decision has been made.
VI. VERIFICATION OF RECEIPT OF NOTICE
-% This acknowledges that I received this notice of non coverage of services under Medicare on
ignature of Re ent or person acting on Resident's behalf
If not signed by Resident indicate relationship to Resident
? D. This is to confirm that you were advised of the non- coverage of the services under Medicare by telephone on / !
Name of person contacted and relationship to the Resident
4gnature of Admi is alive Officer
cc: 1. Attending Physician
2. Patient's Financial Record
KEEP A COPY OF THIS FOR YOUR RECORDS
17
Skilled Nursing Facility Determination
(Medicare Notice of NonCoverage)
Purpose, 1. To notify the patient/resident, in writing as required by federal regulation, that the
care and services he/she requires no longer qualifies for Medicare coverage
Procedure:
Names and Addresses
1. Enter the name of the facility and the facility's address
2. Enter the date the letter is being drafted (this should be the same date that the notice
is given in person or by telephone) to the resident/patient or the responsible party.
3. Enter the name and address of the person who is to be notified.
4. Enter the name of the resident/patient in the "RE. Beneficiary" area.
5. Enter the date the resident/patient was admitted for this Medicare covered period.
6. Enter the resident/patient's Medicare number.
Section I. Technically Ineligible Admission
This section should only be completed if any of the described conditions apply to the
resident/patient's admission. If this section is appropriate and completed the following
sections must also be completed:
III. Non-Certified Bed Placement Consent
VI. Verification of Receipt of Notice.
* Cross out sections 11, IV, and V.
Section III. Admission or Continued Stay - Skilled Care Denial Reason
1.This section is necessary when a resident/patient is technically eligible for Medicare
coverage but does not meet the care requirements either because there are no skilled
care and services or because the care and services are no longer reasonable or
necessary; e.g. the patient has stabilized into a safe pattern of chronic or custodial care.
2. Select the one (1) paragraph that best describes the reason the resident/patient no
longer qualifies for skilled Medicare covered care.
3. When notifying a resident/patient that he or she no longer qualifies for Medicare the
following sections of this form must be comoleted:
A. Names and Addresses
B. Section II "Admission or Continued Stay - Skilled Care Denial Reason"
C. Section III. "Non-Certified Bed Placement Consent" (If the resident will
be moved to a bed which is not certified by Medicare.
D. Section IV. "Appeal Rights"- Signed by the Administrator
E. Section V. "Request for Medicare Intermediary Review"
Section Ill - "Non-Certified Bed Placement Consent" - This section must be completed if the
resident/patient is to be move to a bed that is not certified for Medicare.
Section IV. - "Appeal Rights" - This section should be completed and signed by the Administrator only
when the letter is being given to a resident/patient who is technically qualified for Medicare coverage but
does not meet the care and services requirements for continued Medicare coverage.
Section V. - "Request for Medicare Intermediary Review" This section should be completed only
when the letter is being given to a resident/patient who is technically qualified for Medicare coverage but
does not meet the care and services requirements for continued Medicare coverage.
1. Selection "A" or "B" must be completed.
2. In selection "A" the appropriate Intermediary must be designated
18
3. If the resident/patient or responsible party selects "A" the business
office must be informed and directed to file a "Demand' or "Patient Insist'
bill".
Section VI. "Verification of Receipt of Notice"- This section should always be completed.
1. If the resident/patient or responsible party receives the notice in
person, complete selection "C" and have the person notified sign the
receipt section indicating only that they have received this notice.
2. If the resident/patient or responsible party receives the notice by
telephone complete selection "D" and send a copy of the notice to the
person contacted via a service that provides a signed receipt; e.g.,
certified mail, courier service, Federal Express, et al.
Quick Reference
1. Admission has no three (3) day qualifying stay or does not have Medicare Part A coverage, complete:
A. "Names and Addresses"
B. Section I "Technically Ineligible Admission"
C. Section III "Non-Certified Bed Placement Consent"
D. Section VI. "Verification of Receipt of Notice"
2. Admission or Continued Medicare covered stay is deemed no longer eligible for Medicare coverage;
complete:
A "Names and Addresses"
B. Section 1 "Technically Ineligible Admission"
C Section II "Admission or Continued Stay -Skilled Care Denial Reason
D Section III "Non-Certified Bed Placement Consent"
E Section IV. "Appeal Rights"
F Section V. "Request for Medicare Intermediary Review
G Section VI. "Verification of Receipt of Notice"
3. Letter distribution:
A. Original should be filed in the resident/patient's financial record.
B. Copy number one (1) should be given to the resident/patient or responsible party.
C. Copy number two (2) should be given to the attending physician.
19
K
ATTACHMENT E
MEDICARE SECONDARY PAYOR QUESTIONNAIRE
BENEFICIARY INFORMATION
Medicare Beneficiary: Hinds. Robert N Patient Account #: 2217& HIC #:
Dates of Service From: Through: DCN:
Name of Person Who Supplied the Info tion: Relationship to Patient:
Provider Representative Name: ?^
Input Date: J '-OLI
WORKERS COMPENSATION
1. Per the patient, should this illnesslinjury be covered by a Workers Compensation claim? PLACE Y OR N
If Yes, this should be an MSP or conditional claim, not Medicare Primary. YES or NO-61-
What is the claim number?
What is the original date of injury?
What is the name of the Workers Compensation plan?
What is the address?
City? State? Zip?
FEDERAL BLACK LUNG
2. Is the patient covered by the Federal Black Lung program? YES or NO
If Yes, are any of the claim's diagnosis codes on the Department of Labor's acceptable diagnosis code list? YES or NO
If Yes, this should be an MSP or conditional claim, not Medicare Primary.
Black Lung would not cover SNF stays
DEPARTMENT OF VETERANS AFFAIRS
3. Is the patient entitled to beriefits through the Department of Veterans Affairs? YES or NO
If Yes, does the patient watlt the VA to be contacted for authorization of these services? YES or NO
PUBLIC HEALTH SERVICE
4. Are the services covered by a public health service? YES or NO
If Yes, what is the name of the public health service?
What is the address?
City? State? Zip?
What is the date of the services covered by the public health service?
SNF does not participate in PHS
ACCIDENT
5. Are these services the result of an accident? YES or NO
If Yes, what type of accident was this (For example: Auto, slip and fall [please list location of accident],
malpractice, product liability, homeowners)?
Is non-liability insurance available (For example: Premises medical, auto medical coverage,
no-fault, homeowners premises)? YES or NO
If Yes, what is the name of the insurance company?
What is the address?
City? State? Zip?
What was the date of the accident/injury?
Who is listed as the insured?
20
ACCIDENT(CONTINUED)
5A. Does the patient feel someone else is responsible for the accidentlinjury? YES or NO V-'
if Yes, What is the name of the patient's attorney or the responsible party's insurance company?
What is the address?
City? State? Zip?
What is the name of the responsible insured party?
EMPLOYER GROUP HEALTH PLAN
6. Is the patient covered by any employer group health plan (EGHP), including the Federal Employee Health Benefits YES or NO
or Retirement Policies? If No, this questionnaire is complete. If YES, CONTINUE.
WORKING AGED
7. Is the patient 65 years or older? YES or NO
If Yes, is the patient and/or spouse currently employed by an employer of 20 or more employees? YES or NO
If Yes, is the patient covered by that employer group health plan (EGHP)? YES or NO
If Yes, what is the name of the EGHP?
What is the address?
City? State? Zip?
If the Beneficiary is no longer employed, please give a retirement date if possible:
If the spouse is no longer employed, please give a retirement date if possible:
DISABILITY
8. Is the patient under the age 65? YES or NO
If Yes, is the patient entitled to Medicare solely due to a disability other than end stage renal disease? YES or NO
If Yes, is the patient or family member currently employed by an employer of 100 or more employees? YES or NO
If Yes, is the patient covered by that large group health plan (LGHP)? YES or NO
If Yes, what is the name of the LGHP?
What is the address?
City? State? Zip?
END STAGE RENAL DISEASE(ESRD)
9. Is the patient covered by any EGHP through a current or former employer of any size? YES or NO
Name of group health plan:
Mailing address:
City: State: Zip:
Policy #: Name of policyholder:
Relationship to the patient: Group identification
Name of employer:
Mailing address:
City: State: Zip:
Is the patient within the 30-month coordination of benefits periods? YES or NO-
What is the month/year of the first regular dialysis? (M WDD/CCY)
Has the patient had a kidney transplant? YES or NO
If yes, date of transplant: (MM/DD/CCY)
DUAL ENTITLEMENT
10. Is the patient entitled to Medicare on the basis of either ESRD and age of ESRD and disability? YES or NO
Was the patient's initial entitlement to Medicare (including simultaneous entitlement) based on ESRD? YES or NO
Does the working aged or MSP disability provision apply (i.e. the GHP primary based on the age or disability entitlement)? YES or NO
Note: If Yes to the last question, the GHP remains primary for the 30 month COB period.
21
PRIOR STAY INFORMATION . I
Has this patient been confined to a hospital or skilled nursing facility within the last 60 days?
If Yes, complete the following information for each stay:
Hospital or SNF:
Address:
Admission Date:
By Whom Verified
Discharge Date:
YES or N0 IV
MEMO
22
HCR Manor Care
ATTACIMENT F-1
RESIDENT'S PERSONAL TRUST FUND AGREEMENT
The undersigned hereby agree as follows:
1. The Facility shall furnish the Resident with a written receipt for all expenditures and deposits regarding any
of the Resident's funds deposited with the Facility.
2. A record of all transactions regarding the Resident's funds shall be maintained by the Facility in accordance
with generally accepted accounting principles.
3. The Resident shall have access, at any time upon request, to the above record and shall receive an itemized
quarterly statement of his/her account.
4. The Facility has a surety bond to guarantee the Resident's funds.
5. All Resident personal funds are kept in separate account(s) from the Facility operating accounts.
6. The Facility may keep Fifty and 00/100 Dollars ($50.00) or less in a non-interest bearing or petty cash fund
for the Resident's account. Any money in excess of Fifty and 00/100 Dollars ($50.00) will be put in an interest-bearing
account, with the interest to be credited to the Resident.
7. The Resident acknowledges that, upon his/her discharge or death, the balance of his/her account will be
promptly released to the private party or public agency required by law.
8. The Resident authorizes the Facility to distribute or return the Resident's money only to the Resident or the
Resident's designated representative upon written request.
9. The Facility has no duty to invest the money in the Resident's account to earn income other than interest in a
bank checking or similar account, or to accept a deposit that would cause the balance in the Resident's account to exceed
applicable limits of federal or state law.
10. If the Resident receives Medicaid benefits, the Facility shall notify the Resident when the amount in his/her
account reaches Two Hundred and 00/100 Dollars ($200.00) less than the social security income ("SSI") resource limit
for one person and that, if the amount in the account, in addition to the value of the Resident's other nonexempt
resources, reaches the SSI resource limit for one person, the Resident may lose eligibility for Medicaid or SSI.
I have received the Facility's policies on Resident's Personal Trust Fund Accounts and have had the opportunity to read
the information.
(] I accept the opportunity to deposit funds within the Center.
11K I decline the opportunity to deposit funds within the Center.
Date:
Represen ative (Si a re)
Resident Signature
esponsib Parry (Signature)
Resident Name: Hinds, Robert N
ATTACHMENT F-2
23
ATTACHMENT G1
HCR MANOR CARE
REFUSAL OF LIFE-SUSTAINING TREATMENT.
HCR Manor Care Centers are dedicated to supporting the resident to attain or maintain
his or her highest level or physical, mental, and psychosocial well-being, in accordance with the
resident's personal assessment, his or her individualized Plan of Care, and the resident's wishes
as to medical treatment. The resident's condition, however, may lead him or her to desire to
limit the treatment provided by the Center. In such event, HCR Manor Care Centers will honor
the requests of the resident to refuse life-prolonging treatment, provided that such refusals are
done in accordance with HCR Manor Care's policies. These policies are designed to protect
each resident's rights by following applicable state law governing who can legally consent to
refuse treatment and requiring that the medical record reflect that any other applicable legal
requirements have been satisfied..
HCR MANOR CARE POLICY
HCR MANOR CARE'S policy is to provide all treatment which is medically necessary
to sustain the resident's life, unless a valid order to refuse such treatment is entered in the
resident's medical record by his or her attending physician, in accordance with HCR Manor
Care's Limited Treatment Policy or Policy on "Do Not Resuscitate Orders" ("DNR'%
whichever may be applicable.
Understanding Limited Treatment
HCR Manor Care follows applicable federal and state laws governing the rights of a
resident, whether competent or incompetent, to refuse unwanted medical treatment. An
incompetent resident can direct care through an "advance directive" under applicable state law.
A growing number of states also permit family members to act as "surrogate decision makers" in
the absence of an advance directive. Duly empowered legal guardians might also be permitted to
refuse life-sustaining treatment under applicable state law. Because the laws of each state are
unique, HCR Manor Care has a Limited Treatment Policy for each state. A summary of this
State's laws on advance directives and surrogate decision making is contained in the admissions
packet.
The Limited Treatment Policy imposes procedural requirements for refusing life-
sustaining medical treatment such as mechanical breathing, kidney dialysis, chemotherapy,
blood transfusions, and artificial nutrition and hydration supplied intravenously or through
gastric or nasogastric feeding tubes. Antibiotics might be refused if they are not needed to
alleviate pain and the safety of others in the Center is not threatened.
Whether or not to refuse treatment is a decision to be made by the resident and/or
Responsible Party based upon the advice of the attending physician. HCR Manor Care
recommends that the resident's decisions on the various treatment options be stated with as much
specificity as possible. It is also recommended that the resident execute advance directives and,
25
if a durable power of attorney for health care is executed, that the resident discuss his or her
wishes in detail with the designated person.
Understanding CPR
CPR is emergency medical procedure used in an attempt to restore circulation and
respiration, which have ceased. The cessation of circulation and respiration is referred to as a
cardiopulmonary arrest. It may take several minutes from the onset of a cardiopulmonary arrest
to the point when the condition becomes irreversible. This time interval may represent a
"window of opportunity" when CPR may be effective in restoring circulation and respiration.
CPR consists of both basic and advanced life support procedures. Basic CPR involves rescue
breathing and chest compressions. Rescue breathing is performed mouth-to-mouth or by using a
special mask and bag. Chest compression, or external cardiac massage, is the compression of the
chest at the lower part of the sternum with one's hands, using the weight of one's body for
pressure. It is done to force the circulation of blood through vital organs.
According to reputable industry studies, CPR has significant limitations. It may fail to
restore circulation or respiration. Even if CPR results in the avoidance of death by the traditional
definition, it may be too late to prevent brain damage. Additionally, circulation and respiration
may be restored in time to preserve brain function, but administration of CPR may fracture ribs,
lacerate organs, or result in other injuries. The administration of CPR is most likely to be
successful when the resident is relatively young and does not have a debilitating condition.
Center personnel will perform Basic CPR if a resident has a cardiopulmonary arrest
unless a valid physician order has been entered in the resident's medical chart or CPR would be
unsuccessful in restoring cardiac and respiratory function.
Advanced CPR involves higher technology and will be administered only by paramedics called
to the Center to administer such procedures and to transport the resident to the hospital.
26
ATTACHMENT G2
LIMITED TREATMENT POLICY - PENNSYLVANIA
HCR Manor Care's policy is that all residents will be provided health care unless the
attending physician enters a contrary order in the resident's medical record. The Center will
act to maintain human life in accordance with accepted standards of ethical practice. Health
care will be withheld only in accordance with the procedures set forth in HCR Manor Care's
Limited Treatment Policy for Pennsylvania, which is summarized below.
Competent Resident
A competent resident can refuse medical treatment, including artificial nutrition and
hydration, at any time. The attending physician must, however, record complete information in
the resident's medical record to demonstrate that the decision to refuse treatment was made on
the basis of informed consent.
Incompetent Resident
Pennsylvania law permits decisions to be made on behalf of an incompetent resident in
several ways.
1. Declaration.
If when competent, the resident has executed a living will (known in Pennsylvania as a
"Declaration") in accordance with Pennsylvania law, then life-sustaining treatment can be
withheld in accordance with the resident's instructions set forth in the declaration provided that
the following requirements are met:
a; The attending physician determines that the resident is incompetent;
b. The procedure of treatment proposed to be withheld is consistent with the
specific instructions, if any, of the resident set forth in the Declaration;
c. The attending physician certifies in the medical record that the resident is
either in a terminal condition or is in a state of permanent unconsciousness;
and
d. The attending physician arranges for the physical examination and
confirmation of the terminal condition or state of permanent unconsciousness
by a second physician. If the resident in his or her Declaration designated a
surrogate to make decisions under these circumstances, then the consent of
such surrogate will also be required.
Artificial nutrition and hydration can only be withheld if all of the foregoing
requirements have been met and the Declaration specifically provides for the withholding of
artificial nutrition and hydration.
e. Durable Power of Attorney and no Declaration.
The Pennsylvania Durable Power of Attorney Act authorizes consent for medical
treatment, but does not specifically authorize the withholding of life-sustaining treatment.
Therefore, unless there is a court order providing otherwise, HCR Manor Care may not honor a
27
ti
durable power of attorney for health care. Any such document will be forwarded to the Legal
Department for review.
2. Legal Guardian.
Pennsylvania law may permit a legal guardian to authorize the withholding of life-
sustaining treatment. The scope of the guardian's authority will be verified by the court
documents which appointed the guardian.
3. Close Family Member and Persistent Vegetative State.
If the resident did not executive a valid Declaration or Durable Power of Attorney, or if
the resident does not have a legal guardian with authority to refuse life-sustaining treatment, then
Pennsylvania law permits a family member who is sufficiently close to the resident to render a
judgment on his or her behalf to refuse life-sustaining treatment for a resident who is determined
by two qualified physicians to be in a "persistent vegetative state," provided that there is no
dispute among family members.
Additionally the attending physician must record complete information in the resident's
medical record to demonstrate that the decision of the Responsible Party to refuse treatment was
made on the basis of informed consent and that all other federal and state law requirements have
been satisfied.
28
v
ATTACHMENT H
PRIVACY ACT STATEMENT-HEALTH CARE RECORDS
INFORMATION PERTAINING TO YOU.
1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL
SECURITY NUMBER (SSN)
Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act.
Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive,
accurate, standardized, and reproducible assessments of each resident's functional capacity and
health status. As of June 22, 1998 all skilled nursing and nursing facilities are required to
establish a database of resident assessment information and to electronically transmit this
information to the State. The State is then required to transmit the data to the federal Central
Office Minimum Data Set (MDS) repository of the Health Care Financing Administration.
These data are protected under the requirements of the Federal Privacy Act of 1974 and the
MDS Long Term Care System of Records.
2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED
The information will be used to track changes in health and functional status over time for
purposes of evaluating and improving the quality of care provided by nursing homes that
participate in Medicare or Medicaid. Submission of MDS information may also be necessary
for the nursing homes to receive reimbursement for Medicare services.
3. ROUTINE USES
The primary use of this information is to aid in the administration of the survey and
certification of Medicare/Medicaid long term care facilities and to improve the effectiveness
and quality of care given- in those facilities. This system will also support regulatory,
reimbursement, policy, and research functions. This system will collect the minimum amount
of personal data needed to accomplish its stated purpose.
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The information collected will be entered into the Long Term Care Minimum Data Set (LTC
MDS) system of records, System No. 09-70-1516. Information from this system may be
disclosed, under specific circumstances, to: (1) a congressional office from the record of an
individual in response to an inquiry from the congressional made at the request of that
individual; (2) the Federal Bureau of Census; (3) the Federal Department of Justice; (4) an
individual or organization for a research, evaluation, or epidemiological project related to the
prevention of disease of disability, or the restoration of health; (5) contractors working for
HCFA to carry out Medicare/Medicaid functions, collating or analyzing data, or to detect fraud
or abuse; (6) an agency of a State government for purposes of determining, evaluating and/or
assessing overall or aggregate cost, effectiveness, and/or quality of health care services
provided in the State; (7) another Federal agency to fulfill a requirement of a Federal statute
that implements a health benefits program funded in whole or in part with Federal funds or to
detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII
functions, (9) another entity that makes payment for or oversees administration of health care
services for preventing fraud or abuse under specific conditions.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON
INDIVIDUAL OF NOT PROVIDING INFORMATION
For nursing home residents residing in a certified Medicare/Medicaid nursing facility the
requested information is mandatory because of the need to assess the effectiveness and quality
of care given in certified facilities and to assess the appropriateness of provided services. If a
nursing home does not submit the required data it cannot be reimbursed for any
Medicare/Medicaid services.
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I
ATTACHMENT I-1
NOTICE OF INFORMATION PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY.
We have summarized our responsibilities and your rights on this first page. For a complete
description of our information practices, please review this entire notice.
Our Responsibilities
We are required to:
Maintain the privacy of your health information;
Provide you with this notice of our legal duties and information practices with respect
to information we collect and maintain about you; and
Abide by the terms of this notice.
Your Rights
You have several rights with regard to your health information. Those include the right to:
¦ Request that we not use or disclose your health information in certain ways;
¦ Request to receive communications in an alternative manner or location;
¦ Access and obtain a copy of your health information;
¦ Request an amendment to your health information; and
¦ An accounting of disclosures of your health information;
We reserve the right to change our information practices and to make the new provisions
effective for all health information we maintain. Should our privacy practices change, we will
post the changes in a physical place within our building and on our web site. A copy of the
revised notice will be available after the effective date of the changes upon request.
We will not use or disclose your health information without your authorization, except as
described in this notice.
If you have questions and would like additional information, you may contact Randy Holtry,
NHA, 717-263-0436.
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Entities Covered Under This Notice
Manor Care, Inc. through its operating group HCR Manor Care, is the owner and operator of several
entities which operate primarily under the Heartland, ManorCare, and Arden Court names. The following
entities are part of an organized health care arrangement:
¦ Skilled Care Facilities - provide comprehensive health care around the clock by experienced
professionals.
¦ Assisted Living Facilities - provide personal care assistance as needed for dressing, bathing, meal
preparation and medication management for residents who live independently.
¦ Rehabilitation Companies - provide in-patient and out-patient therapy services for those
recovering from illnesses, injuries, or disabilities.
¦ Home Health Care - provide health care in the home so that patients may stay at home while
receiving needed care to function.
¦ Hospice Services - provide hospice services to assist those dealing with terminal illness.
¦ Medicare Part B Provider - Provides certain medical products for eligible individuals.
¦ Pharmacy Products and Services - provide pharmaceuticals to patients who need pharmacy
services.
¦ Physician Services - provide management services to physician practices.
These entities are all affiliated with the same parent company, Manor Care, Inc. The entities participating
in the organized health care arrangement will share health information with each other as necessary to
carry out treatment, payment, or health care operations. Each entity will abide by the terms of this notice
with respect to protected health information received by another participating entity.
Understanding Your Health Record
Each time you visit a medical provider, a record of your visit is made. Typically, this record contains
your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.
This information, 'often referred to as your health or medical record, serves the following purposes:
Basis for planning your care and treatment
Communication among health professionals involved in your care
Legal document describing the care you received
Proof that services billed were actually provided
A tool to educate health professionals
A source of data for medical research
A source of information for public health officials who oversee the delivery of health care in the United
States
A tool to measure and improve the care we give
Understanding what is in your record and how your health information is used helps you to:
Ensure its accuracy
Understand who, what, when, where, and why others may access your health information
Make informed decisions when authorizing disclosure to others.
How We Will Use or Disclose Your Health Information.
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For Treatment. We will use and disclose your personal health information in providing you with
treatment and services. We may disclose your personal health information to personnel who may be
involved in your care, such as physicians, nurses, nurse aides, physical therapists, dietary and admissions
personnel. For example, a nurse caring for you will report any change in your condition to your
physician. We also may disclose personal health information to individuals who will be involved in your
care after you leave the facility.
For Payment. We may use and disclose your personal health information so that we can bill and receive
payment for the treatment and services you receive. For billing and payment purposes, we may disclose
your personal health information to your representative, an insurance or managed care company,
Medicare, Medicaid or another third party payer. For example, we may contact Medicare or your health
plan to confirm your coverage or to request prior approval for a proposed treatment or service.
For Health Care Operations. We may use and disclose your personal health information for our regular
health operations. These uses and disclosures are necessary to manage our operations and to monitor our
quality of care. For example, we may use personal health information to evaluate our services, including
the performance of our staff. We may use a photograph of you to identify you or for general programs
such as posting on activity boards.
Business Associates. Outside people and entities provide some services for us. Examples of these
"business associates" include our accountants, consultants and attorneys. We may disclose your health
information to our business associates so that they can perform the job we've asked them to do. We
require the business associates to safeguard your information so that it is protected.
Directory. Unless you notify us that you object, we may use your name, location in the facility, general
condition, and religious affiliation for directory purposes. We may release information in our directory,
except for your religious affiliation, to people who ask for you by name. We may provide the directory
information, including your religious affiliation, to any member of the clergy.
Notification. We may use or disclose information to notify or assist in notifying a family member,
personal representative, or another person responsible for your care, of your location and general
condition. If we are unable to reach your family member or personal representative, then we may leave a
message for them at the phone number that they have provided us, e.g. on an answering machine.
Communication with Family. We may disclose to a family member, other relative, close personal friend
or any other person involved in your health care, health information relevant to that person's involvement
in your care or payment related to your care.
Bulletin Boards/Newsletters. We may post your name and birth date on a facility bulletin board or in a
facility newsletter.
Research. We may disclose information to researchers when certain conditions have been met.
Transfer of Information at Death. We may disclose health information to funeral directors, medical
examiners, and coroners to carry out their duties consistent with applicable law.
Organ Procurement Organizations. Consistent with applicable law, we may disclose health information
to organ procurement organizations or other entities engaged in the procurement, banking, or
transplantation of organs for the purpose of tissue donation and transplant.
Marketing. We may contact you regarding your treatment, to coordinate your care, or to direct or
recommend alternative treatments, therapies, health care providers or settings. In addition, we may
contact you to describe a health-related product or services that may be of interest to you, and the
payment for such product or service.
Fund raising. We may contact you as part of a fund-raising effort.
Food and Drug Administration (FDA ).We may disclose to the FDA, or to a person or entity subject to the
jurisdiction of the FDA, health information relative to adverse events with respect to food, supplements,
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product and product defects, or post marketing surveillance information to enable product recalls, repairs,
or replacement.
Worker's compensation. We may disclose health information to the extent authorized by and to the
extent necessary to comply with laws relating to workers' compensation or other similar programs
established by law.
Public health. As required by law, we may disclose your health information to public health or legal
authorities charged with preventing or controlling disease, injury, or disability.
Correctional institution. Should you be an inmate of a correctional institution, we may disclose to the
institution or agents thereof health information necessary for your health and the health and safety of
other individuals.
Law enforcement. We may disclose health information for law enforcement purposes as required by law
or in response to a valid subpoena.
Reports. Federal law allows a member of our work force or a business associate to release your health
information to an appropriate health oversight agency, public health authority or attorney, if the work
force member or business associate believes in good faith that we have engaged in unlawful conduct or
have otherwise violated professional or clinical standards and are potentially endangering one or more
patients, workers or the public.
Your Health Information Rights
You have the following rights regarding your personal health information:
Right to Request Restrictions. You have the right to request restrictions on our use or disclosure of your
personal health information for treatment, payment or health care operations. You also have the right to
restrict the personal health information we disclose about you to a family member, friend or other person
who is involved in your care or the payment for your care.
We are not required to agree to your requested restriction (except that while you are competent you may
restrict disclosures to family members or friends). If we do agree to accept your requested restriction, we
will comply with your request except as needed to provide you emergency treatment.
Right of Access to Personal Health Information. You have the right to inspect and obtain a copy of your
medical or billing records or other written information that may be used to make decisions about your
care, subject to some limited exceptions. Such records will be provided to you in the time frames
established by law. We may charge a reasonable fee for our costs in copying and mailing your requested
information.
We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied
access to personal health information, in some cases you will have a right to request review of the denial.
Right to Request Amendment. If you believe that any health information in your record is incorrect or if
you believe that important information is missing, you may request that we correct the existing
information or add the missing information. Such requests must be made in writing, and must provide a
reason to support the amendment.
We may deny your request for amendment in certain circumstances. If we deny your request for
amendment, we will give you a written denial including the reasons for the denial and the right to submit
a written statement disagreeing with the denial.
Right to an Accounting of Disclosures. You have the right to request an "accounting" of our disclosures
of your personal health information. This is a listing of certain disclosures of your personal health
information made by the us or by others on our behalf, but does not include disclosures for treatment,
payment and health care operations or certain other exceptions.
To request an accounting of disclosures, you must submit a request in writing, stating a time period
beginning after April 13, 2003 that is within six years from the date of your request. An accounting will
include, if requested: the disclosure date; the name of the person or entity that received the information
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and address, if known;,a brief description of the information disclosed; a brief statement of the purpose of
the disclosure or a copy of the authorization request; or certain summary information concerning multiple
similar disclosures. The first accounting provided within a 12-month period will be free; for further
requests, we may charge you our costs.
Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if
you have agreed to receive this Notice electronically. You may request of copy of this Notice at any time.
Right to Request Confidential Communications. You have the right to request that we communicate with
you concerning personal health matters in a certain manner or at a certain location. For example, you can
request that we contact you only at a certain phone number. We will accommodate your reasonable
requests.
Right to Revoke Authorization. You may revoke an authorization to use or disclose health information,
except to the extent that action has already been taken. This request must be made in writing.
For More Information or to Report a Problem
If you believe that your privacy rights have been violated, you may file a complaint in writing with us or
with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a
complaint with us, contact RandyHoltry, NHA, 717-263-0436. We will not retaliate against you if
you file a complaint.
If you have any questions about this Notice or would like further information concerning your privacy
rights, please contact Randy Holtry, 717-263-0436.
Effective Date: April 14, 2003
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ATTACHAMNT I-2
RECEIPT OF NOTICE OF INFORMATION PRACTICES
Resident's Name: Hinds, Robert, N
I acknowledge receipt of HCR Manor Care's Notice of Information Practices.
I agree object to including Hinds, Robert, N location in the facility, general condition
and religious affiliation (available to clergy only) in the Facility Directory.
I \/agree object to disclosure of Hinds, Robert, N health information to a family member
or close personal friend, including clergy, who is involved in my care.
40--2-ifd Name JP`l?ease Print) Si ture 4
Relationship to Resident Date
---- ------------------ - - -----------------
To be completed by Facility Personnel
A good faith effort was made to obtain written acknowledgement of the Notice of Information
Practices.
1---Written acknowledgment was obtained
Written acknowledgment was not obtained. Efforts to obtain receipt and reason not
obtained are described below.
Co p Aeted thy: 1
Name Signat a Date
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1i1cill1ll11 sercit?cs AItIIIII;T>>rC)l Int.
ATTACHMENT J
ASM
Ancillary Services Management, Inc.("ASM") is a national Medicare Part B provider and
may have an agreement with this facility to provide certain medical products for eligible
nursing home residents. ASM provides the following: nutritional supplies for tube
feeding, foley catheters for urological patients, surgical dressing supplies, orthotics, as
well as ostomy and tracheostomy supplies for those patients who require them.
If ASM is available in the facility, the resident and/or responsible party selects ASM to
provide Medicare Part B supplies ordered by the resident's attending physician.
The resident and/or responsible party request that Medicare benefits be paid directly to
ASM for any medical supplies provided to the resident which are covered under Medicare
Part B and authorize ASM to bill and collect for such medical supplies directly from
Medicare or other third party payor.
The Resident and/or Responsible Party further authorize any holder of medical information about the
resident to release to the third party payor(s) and its agents any information needed to determine these
benefits.
Date Resident Signature ! -- . I- -?,
2
OY - -
Date Sign p nsibl arty
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ATTESTATION OF ADMISSION AGREEMENT AND ATTACHMENT
I 4L
, on behalf of the Center HCR ManorCare-
hambersb
Name Center
certify, as indicated by my initials set forth below, that I have provided the Resident
and/or Responsible Party of Hinds, Robert N with the Admission Agreement and each of
the attachments listed below. I also acknowledge that I have reviewed each of the
attachments with the Resident and/or Responsible Party, that the Resident and/or
Responsible Party have had the opportunity to ask questions and have had all of their
questions answered satisfactorily. The Resident and/or Responsible Party have signed
each of the required documents in my presence indicating receipt and understanding.
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 and/or 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-1 and F-2.
jLe. Center Supplement:
1. Policy and procedure on bedholds, election of bedholds 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 unit.
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 certification agency
concerning resident abuse, neglect, mistreatment and
misappropriation of property.
-&f. The Resident Handbook.
. Resident/Patient Rights.
h. Medicare/Medicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments.
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i. Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR 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-1 and G-2.
Privacy Act Notification. See Attachment H.
k. Notice of Information Practices and Receipt of Notice of Information
Practices. See Attachments I-1 and I-2.
1. Ancillary Services Management Form. See Attachment J.
I have requested that the Resident and /or the Responsible Party provide the following
documents as applicable:
a. Copy of Medicare Card for file.
b. Copy of Medicaid Card for file.
c. Copy of Social Security Card for file.
d. Copy of all insurance cards for file.
e Copy of Prescription Card for file. Note: please copy both sides of card.
f. Copy of Living Will for file.
g. Copy of Health Care and Financial Power of Attorney for file.
`~- h. Copy of Guardianship or Health Care Surrogate papers for file.
Name Date
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HCR Manor Care
Pennsylvania
ADMISSION AGREEMENT
This Agreement is entered into by and among HCR ManorCare-Chambersburg, 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 respect to the
Resident's stay at this HCR Manor Care's Center ("Center").
Center: HCR ManorCare-Chambersburs
Admission Date: 06/25/2004 Deposit: $
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.
Resident: Hazel S. Hinds
Responsible Party: C Inds *Z,&1 S , 1 ndS
1. RIGHTS AND RESPONSIBILITIES 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 as well as the day
of discharge. This Section will not apply if the Resident is covered under a governmental
program (see Section 1.05) 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
succeeding month, and are payable in full, along with the Room and Board Rate upon receipt.
1.03 Collections/Late Payments. Payment is due in full within thirty (30) days of
billing. Should the Resident's account for any reason be turned over for collection, the Resident
will pay the Center's collection costs, including attorney's fees.
1.04 Independent Providers. The Resident is directly responsible to 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 Pro rg ams. 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 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 pay residents in accordance with Sections 1.01 and 1.02.
The Center participates in the following programs: V <edicare,V Medicaid and/or VA.
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 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. The Resident and/or Responsible
Party are responsible for applying for Medicaid. 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 agrees 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 fails to pay the contribution amount, the
Center may take such legal action as necessary, including requesting a court to order such
payment.
1.06 Third PgKly Payors and Managed Care Organizations. If a Resident is a
participant in a plan offered by a third party payor such as a Health Maintenance Organization
("HMO"), Preferred Provider Organization ("PPO"), Provider Sponsored Organization ("PSO"),
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 applicable
agreement. The Resident 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
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will bill the Resident's third party payor as a service, but the Resident remains liable 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 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 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
and/or 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-payment in accordance with this Agreement, Resident Handbook
and state and federal laws.
1.08 Admission Information. The Resident and/or Responsible Party will notify the
Center and provide any needed information regarding all third parry payors or governmental
coverages on admission and throughout the Resident's stay including copies of insurance cards,
identification or verification of eligibility and coverage information.
The Resident and/or Responsible Party will provide the Center in writing with
notice within five (S) 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 the 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, managed 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 Primary Responsibility for Payent. Except 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,
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 written notice that the Center has notified the
Resident and/or Responsible Party that services provided at the Center may not be covered by a
governmental payor, third party payor or managed care organization. The Resident and/or
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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.
1.11 Personal Physician. The Resident has the right to choose a personal 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 name of his/her 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 needed coverage and
attendance or fails to abide by applicable laws and regulations, the Center will 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 medication distribution system similar to the Center's ancillary pharmacy's medication
distribution system.
H. RIGHTS AND RESPONSIBILITY OF THE RESPONSIBLE PARTY
2.01 Legal Authority. The Responsible Party represents that he/she has legal access to
the Resident's income or resources and that the documents supporting such authority, if any,
have been delivered to the Center.
2.02 Agreement to Make Payments on Behalf of Resident. The Responsible Party will
pay promptly 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 financial
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 for any services
or products specifically requested by the Responsible Party to be supplied to the Resident, unless
such services or products are covered by a governmental program.
2.04 Exhaustion 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
for nonpayment upon reasonable and appropriate notice, as provided in Section 4.06. In
addition, if the Responsible Party fails to notify the Center in writing or fails to file for Medicaid
in a timely and proper manner, the Responsible Party will be personally liable for all charges and
4
fees not covered by Medicaid which otherwise would have been covered had application been
made in a timely and proper manner.
2.05 Cooveration for Financial Assistance. If the Resident is eligible for 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
Resident's care, the Resident may be discharged or transferred upon appropriate and reasonable
notice for nonpayment, as provided in Section 4.06.
2.06 Acceptance Upon Discharge. 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 requested, 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 purposes of
avoiding the Responsible Party's obligation to make payments on behalf of the Resident under
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.
III. RIGHTS AND RESPONSIBILITIES 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 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, safety and general well-being of the
Resident.
5
r
3.02 Other Services. The Center will act in accordance with the Resident Handbook,
which is incorporated by reference in this Agreement.
3.03 Deposit. The Center acknowledges receipt of the Deposit, if any, noted at the
beginning of this Agreement. The Deposit will 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 law. In the case of Medicaid Residents, any such refund will be paid within thirty (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 of Information. 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 or 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 Consent to Treat. The Resident and/or Responsible Party 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 documents
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 Photograph. 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.
6
4.04 Notice of Services, Policies 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, if applicable. The Resident and/or
Responsible 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
and/or 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-1 and F-2.
e. Center Supplement:
1. Policy and procedure on bedholds, election of bedholds 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 unit.
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 certification agency
concerning resident abuse, neglect, mistreatment and
misappropriation of property.
f. The Resident Handbook.
g. Resident/Patient Rights.
h. Medicare/Medicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments.
i. Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR 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-1 and G-2.
j. Privacy Act Notification. See Attachment H.
k. Notice of Information Practices and Receipt of Notice of Information
Practices. See Attachments I-1 and I-2.
1. Ancillary Services Management Form. See Attachment J.
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 and/or
Responsible Party authorize the Center and any holder of medical or other information to release
such information to the Centers for Medicare and Medicaid Services "CMS" and its agents and
to third party payors any information needed to determine these benefits or benefits for related
services.
4.06 Termination, Discharge 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 of the 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 the 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
Y
of any person or entity (including the Center), except in the case of negligence of the Center's
employees and agents.
9
4.08 Changes in the Law. Any provision of this 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 will continue to fulfill their respective obligations under this Agreement consistent with
the law.
THE UNDERSIGNED CERTIFY AND ACKNOWLEDGE THAT THEY HAVE
EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT
THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY
QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION.
Signature of Resident: Date: -15 -(
Signature of Responsible Party:
Date:
Center Representative: L44) Date: to ?c?-y
ATTACHMENT A
ROOM AND BOARD RATE
The Resident will pay the following mc14. nthly rate:
Semi-Private Room: S 1 3 od
3-Bed Room:
Subacute Semi-Private Room:
3-Bed Room:
Private Room:
4-Bed Room:
Subacute Private Room:
4-Bed Room:
11
4 '
ATTACHMENT B
ANCILLARY CHARGES
The services and supplies categorically described on this Attachment are not included in the
basic Room and Board Rate. Therefore, the Resident will be individually billed for these items in
accordance with Section 1.02 of the Admission Agreement. A complete list of ancillary items,
together with the current price, is on file at the Center's business office.
Personal laundry and dry cleaning.
Personal care items, such as toothbrush, toothpaste, mouthwash, deodorant, hairbrush, Efferdent,
tissues, razors, etc.
Beauty and Barber Shop services
Tobacco and smoking supplies, newspapers and periodicals
Stationary, postage, and writing implements
Radios, televisions, cable service, room telephone
Transportation for non-medical purposes and ambulance charges
Photocopies of medical records
Personal physicians and specialists
Dental services and Dentures
Optometrist/Ophthalmologist services and Eyeglasses
Podiatry services
Special nursing services, such as hand feeding, and care for catheters, decubiti, incontinence,
isolation and dressings
Therapy services, including physical, speech, occupational, audiology and respiratory therapy
Prescription and non-prescription medication
Laboratory and x-ray tests
Oxygen an&related supplies
IV Therapy and supplies
Peritoneal dialysis
Tracheotomy supplies
Ventilator rental and related supplies
Medical supplies, including but not limited to syringes, dressings, catheters, colostomy bags, tubes,
surgical stockings, and all other supplies necessary for the treatment, nursing care, or well-
being of the Resident
Incontinence supplies
Special equipment (for some items, a rental, rather than purchase fee is charged), such as
wheelchairs, wheelchair pad, trapeze, canes, geri-chair, special mattresses, porta-chairs, etc.
Special, supplementary, or very low calorie prescription dietary products, including liquid for gastric
and naso-gastric tubes, and any supply necessary to accomplish special feedings.
12
HCR Manor Care
ATTACHMENT C
ASSIGNMENT FOR PAYMENT OF BENEFITS
RESIDENT'S NAME: Hinds. Hazel S
SOC. SEC. NUMBER: 171-28-2085
MEDICARE NUMBER: 171282085A
ADMISSION DATE: 06/25/2004
I, Hinds. Hazel S, authorize my insurance company, third party payer or
governmental payer to pay HCR ManorCare-Chambersbura directly for healthcare services
rendered to me or my named dependent identified below and assign the right to receive
payment of those benefits to the Center.
I also consent to the use and disclosure of my and my named dependent's protected
health information for purposes of obtaining payment for healthcare services provided to me
or my named dependent.
I understand that this assignment applies to those eligible charges for which I am
covered by my insurance company's benefit or third party payer and that any additional
and/or denied charges are entirely payable by me.
A copy of this will serve as an original.
ignatur of Resident
And/Or Responsible Party
Date
Date
(Copies to Resident/Responsible Party and Center.)
Resident Name: Hinds, Hazel S Medical Record Number: 22477
13
ATTACHMENT D
HCR Manor Care
SKILLED NURSING FACILITY DETERMINATION
SNF Name: HCR ManorCare-Chambersbura Address: 1070 Stouffer AvE
DATE: _-J--J_ Chambersbura. PA 17201
T0: Name: Chris Hinds RE: Beneficiary Hazel S. Hinds
Address: 39 Larth Drive Admission Date: 0612512004
City, State, Zip: Shiooensbura. PA 17257 Medicare Number (HIC#): 171282085A
ADMISSION
1. TECHNICALLY INELIGIBLE On 1 1 we reviewed your medical information available at the time of, or prior to admission, and we believe that the service(s)
I beneficiary name) needed did not meet the requirements for coverage under Medicare. The reason is:
? You had no 3 day hospital qualifying stay
? You have previously exhausted your 100 Medicare days coverage
? You are not entitled to Medicare Part A
? Your discharge from the hospitaVSNF has exceeded 30 days
II If the resident is waiving Medicare benefits complete the "Voluntary Waiver of Medicare Benefits' Letter"
li. ADMISSION or CONTINUED STAY - SKILLED CARE DENIAL
n Facility Decision n Utilization Review Committee Decision
On I I , we reviewed your medical information and found that the services fumished (you)
qualified as covered under Medicare beginning / / . The reason is:
? You have used the full 100 days of Medicare coverage allowed under the Medicare program for Skilled Nursing facility coverage.
no longer
? Medicare covers medically necessary skilled nursing care needed on a daily basis. You only needed oral medications, assistance with your daily
activities and general supportive services. There is no evidence of medical complications or other medical reasons that required the skills of a
professional nurse or therapist to safely and effectively carry out your plan of care. Therefore, we believe that your care cannot be covered under
Medicare.
? Medicare covers medically necessary skilled care needed on a daily basis. You only needed . This does not require the
skills of a licensed nurse to perform the service or to manage your care. Since you needed neither skilled nursing nor skilled rehabilitation on a daily
basis, we believe your stay is not covered under Medicare.
? Medicare covers medically necessary skilled care needed on a daily basis. You only needed after I I
Since you no longer require skilled nursing and did not need skilled rehabilitation on a daily basis, we believe your stay beginning I I is not
covered under Medicare.
? Medicare covers medically necessary skilled care needed on a daily basis. You needed skilled nursing care beginning I 1 to observe and
evaluate your condition. There is no indication of further likelihood of significant changes in your care plan or of acute changes or complication in your
condition. Since you no longer need skilled nursing or skilled rehabilitation services on a daily basis, we believe your stay after J I is not
covered under Medicare.
? Medicare covers medically necessary skilled care needed on a daily basis. Because of your condition you needed a skilled nurse from / I
through I I to evaluate and manage your care plan. Your condition has improved so the services you need can safely and effectively be
given by non skilled persons. Since you no longer require skilled nursing and did not need skilled rehabilitation services on a daily basis, we believe
your stay is not covered under Medicare after / I
? Medicare covers medical necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time
where progressive learning is demonstrated. You have learned to perform the tasks ordered by your physician by I 1 but the therapist
continued services. Since you did not need skilled services after that date, we believe your stay is not covered under Medicare beginning
1 I
0 Medicare covers medical necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time
where progressive learning is demonstrated. You needed only to be reminded to follow the physician's instructions. This does not require the skills of
a professional nurse or therapist. Therefore, we believe that this service is not covered under Medicare.
? Medicare covers medically necessary skilled nursing or rehabilitation services you need including teaching and training activities for a reasonable time
where progressive learning is demonstrated. You received teaching and training for a reasonable time but demonstrated you were not able, at this
time, to learn or make progress to perform the activities ordered by your physician. Therefore, we believe that skilled services are not covered under
Medicare after I I
15
? Medicare covers daily skilled nursing care related to the insertion, sterile irrigation and replacement of urethral catheter if the use of the catheter is
reasonable and necessary for the active treatment of a disease of the urinary tract or for patients with special medical needs. Skilled nursing is not _
considered medically necessary when urethral catheters are used only for mere convenience or the control of incontinence. Since your catheter was
inserted for convenience or the control of your incontinence. We believe that your care is not covered under Medicare.
Q Medicare covers medically necessary skilled rehabilitation services. The medical information stows that the only therapy services you needed
beginning 1 I were repetitive exercises and help with walking. These do not generally require the skills or the supervision of a qualified
therapist. There was no evidence of medical complications which would have required that services be performed by a qualified therapist. We
believe therapy services are not covered under Medicare after / /
? Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis. The therapy services you received were for your
overall fitness and general well-being. They did not require the skills of a qualified therapist to perform and I or to
supervise the services. Since you did not need skilled nursing or skilled rehabilitation services, we believe your stay is not covered under Medicare.
? Medicare covers medically necessary skilled rehabilitation services to establish a safe and effective program to maintain your functional abilities. This
program was established and beginning I / , the therapy services you received were to carry out this program. These
services do not require the supervision or skiNs of a therapist and, therefore, we believe that the services are not/ would not be
covered under Medicare.
? Medicare covers medically and necessary skilled care when needed on a daily basis. The (specify services) you
received islare considered a skilled service by Medicare. However based on the medical information provided, this/these services(s) is noVare not
considered a specific and /or effective treatment for your condition. Since the services(s) you received was nottwere not reasonable or necessary for
the treatment of your condition, we believe your stay is not covered under Medicare.
? Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis. The therapy services
provided was not/were not reasonable in relation to the expected improvement in your condition. In this case, since you do not need skilled nursing on
a daily basis and the therapy services are not considered reasonable and necessary, we believe, your stay is not covered under Medicare.
0 Medicare covers medically necessary skilled rehabilitation services when needed on a daily basis. While you required skilled
from I I to I I , the medical information shows that the therapy services after that time are not
reasonable in relation to the expected improvement in your condition. In this case, since you do not need skilled nursing on a daily basis and the
therapy services are not considered reasonable and necessary, we believe, your stay after I I is not covered under Medicare.
? Medicare covers medically necessary skilled care when needed on a daily basis. Although (service) generally requires the
skills of a , the frequency with which the service is given must be in accordance with accepted standards of medical
practice. The service(s) you received is notlare not normally needed on a daily basis. The medical information does not show medical complications which
require the services to be performed on a daily basis. In this case, the services are not considered reasonable and necessary. Since you did not need skilled
nursing or skilled rehabilitation on a daily basis, we believe your stay is not covered under Medicare.
This decision has no{ been made by Medicare. It represents pour (or) p the Utilization Review Committee's judgment that the services you needed did not meet or no
longer met Medicare payment requirements. A bill will be sent to Medicare for services you received before I / . Normally, the bill submitted to Medicare does
not include services provided after this date. If you want to appeal this decision, you must request that the bill submitted to Medicare include the services we determined
to be non-covered. Medicare will notify you of its determination. If you disagree with that determination you may file an appeal.
111. • 1 / PLACEMENT CONSENT
n We are placing you in a part of this facility which is not appropriately certified by Medicare because you do not require a level of care that will qualify as skilled nursing
care. Nonqualifying services furnished a patient in a non-certified or in appropriately certified bed are not payable by Medicare. .
Under a provision of the Medicare law, you do not have to pay for non-covered services determined to be custodial care or not reasonable and necessary unless you
had reason to know the services were non-covered. You are considered to know that these services were non- covered effective with the date of this notice. If you have
questions concerning your liability for payment for services you received prior to the date of this notice, you must request that a bill b e submitted to Medicare. We regret
that this may be your first notice of the non:coverage of services under Medicare. Our efforts to contact you earlier in person or by telephone were unsuccessful. Please
check one of the boxes below to indicate whether or not you want your bill submitted to Medicare and sign the notice to verify receipt.
Sincerely yours,
Signature of Administrative Officer
16
V. REQUEST FOR MEDICARE INTERMEDIARY REVIEW
? A. I do want my bill for services I continue to receive to be submitted to the intermediary for a Medicare decision. You will be informed
when the bill is submitted. If you do not receive a formal Notice of Medicare Determination within 90 days of this request you should
contact:
n AdminaStar Federal 801A W. Br" St. Cincinnati. 0. 45203
n CareFirst (Blue cross or Maryland) 1946 Greenspring Dr. Timonium, Md. 21093
n
Name and Address of Intermediary
? B. I do not want my bill for services I continue to need to be submitted to the Intermediary for a Medicare decision. I understand that 1 do not
have Medicare rights if a bill is not submitted. Note: Beginning October 1, 1989, you are not required to pay for services which could be
covered by Medicare until a decision has been made.
VI. VERIFICATION OF RECEIPT OF NOTICE
? C. This acknowledges that I received this notice of non coverage of services under Medicare on / I
Signature of Resident or person acting on Resident's behalf
if not signed by Resident indicate relationship to Resident
? D. This is to confirm that you were advised of the non- coverage of the services under Medicare by telephone on t 1
Name of person contacted and relationship to the Resident
Signature of Administrative Officer
cc: 1. Attending Physician
2. Patient's Financial Record
KEEP A COPY OF THIS FOR YOUR RECORDS
17
I
Skilled Nursing Facility Determination
(Medicare Notice of NonCoverage)
Purpose: 1. To notify the patient/resident, in writing as required by federal regulation, that the
care and services he/she requires no longer qualifies for Medicare coverage
Procedure:
Names and Addresses
1. Enter the name of the facility and the facility's address
2. Enter the date the letter is being drafted (this should be the same date that the notice
is given in person or by telephone) to the resident/patient or the responsible party.
3. Enter the name and address of the person who is to be notified.
4. Enter the name of the resident/patient in the "RE: Beneficiary" area.
5. Enter the date the resident/patient was admitted for this Medicare covered period.
6. Enter the resident/patient's Medicare number.
Section I. Technically Ineligible Admission
This section should only be completed if any of the described conditions apply to the
resident/pabenfs admission. If this section is appropriate and completed the following
sections must also be completed:
Ill. Non-Certified Bed Placement Consent
VI. Verification of Receipt of Notice.
* Cross out sections II, IV, and V.
Section II. Admission or Continued Stay - Skilled Care Denial Reason
1.This section is necessary when a resident/patient is technically eligible for Medicare
coverage but does not meet the care requirements either because there are no skilled
care and services or because the care and services are no longer reasonable or
necessary; e.g. the patient has stabilized into a safe pattern of chronic or custodial care.
2. Select the one (1) paragraph that best describes the reason the resident/patient no
longer qualifies for skilled Medicare covered care.
3. When notifying a resident/patient that he or she no longer qualifies for Medicare the
following sections of this form must be completed:
A. Names and Addresses
B. Section If "Admission or Continued Stay - Skilled Care Denial Reason"
C. Section III. "Non-Certified Bed Placement Consent" (If the resident will
be moved to a bed which is not certified by Medicare.
D. Section IV. "Appeal Rights"- Signed by the Administrator
E. Section V. "Request for Medicare Intermediary Review"
Section Ill - "Non-Certified Bed Placement Consent" - This section must be completed if the
resident/patient is to be move to a bed that is not certified for Medicare.
Section IV. - "Appeal Rights"- This section should be completed and signed by the Administrator only
when the letter is being given to a resident/patient who is technically qualified for Medicare coverage but
does not meet the care and services requirements for continued Medicare coverage.
Section V. - "Request for Medicare Intermediary Review" This section should be completed only
when the letter is being given to a resident/patient who is technically qualified for Medicare coverage but
does not meet the care and services requirements for continued Medicare coverage.
1. Selection "A" or "B" must be completed.
2. In selection "A" the appropriate Intermediary must be designated
18
i
3. If the resident/patient or responsible party selects "A"the business
office must be informed and directed to file a "Demand' or "Patient Insist"
bill".
Section VI. "Verification of Receipt of Notice"- This section should always be completed.
1. If the resident/patient or responsible party receives the notice in
person, complete selection "C" and have the person notified sign the
receipt section indicating only that they have received this notice.
2. If the resident/patient or responsible party receives the notice by
telephone complete selection "D" and send a copy of the notice to the
person contacted via a service that provides a signed receipt; e.g.,
certified mail, courier service, Federal Express, et al.
Quick Reference
1. Admission has no three (3) day qualifying stay or does not have Medicare Part A coverage, complete:
A. "Names and Addresses"
B. Section I "Technically Ineligible Admission"
C. Section III "Non-Certified Bed Placement Consent"
D. Section VI. "Verification of Receipt of Notice"
2. Admission or Continued Medicare covered stay is deemed no longer eligible for Medicare coverage;
complete:
A "Names and Addresses"
B. Section I "Technically Ineligible Admission"
C Section II "Admission or Continued Stay - Skilled Care Denial Reason
D Section III "Non-Certified Bed Placement Consent"
E Section IV. "Appeal Rights"
F Section V. "Request for Medicare Intermediary Review
G Section VI. "Verification of Receipt of Notice"
3. Letter distribution:
A. Original should be filed in the resident/patient's financial record.
B. Copy number one (1) should be given to the resident/patient or responsible party.
C. Copy number two (2) should be given to the attending physician.
19
ATTACHMENT E
MEDICARE SECONDARY PAYOR QUESTIONNAIRE
BENEFICIARY INFORMATION
Medicare Beneficiary: Hinds, Hazel S Patient Account #: 22477 H1C #: 171282085A
Dates of Service From: '` ' Through: DCN:
iowAXyyAz, Relationship to Patient:
Name of Person Who Supplied
tiv
t
id
R
Name: JLt
P
njA Input Date:
e
epresen
a
rov
er
WORKERS COMPENSATION
1. Per the patient, should this illnesslinjury be covered by a Workers Compensation claim? PLACE Y OR N
If Yes, this should be an MSP or conditional claim, not Medicare Primary. YES or NO
What is the claim number?
What is the original date of injury?
What is the name of the Workers Compensation plan?
What is the address?
City? State? Zip?
FEDERAL BLACK LUNG
2. Is the patient covered by the Federal Black Lung program? YES or NO
If Yes, are any of the claim's diagnosis codes on the Department of Labor's acceptable diagnosis code list? YES or NO
If Yes, this should be an MSP or conditional claim, not Medicare Primary.
Black Lung would not cover SNF stays
DEPARTMENT OF VETERANS AFFAIRS
3. Is the patient entitled to bdnefits through the Department of Veterans Affairs? YES or NO
If Yes, does the patient wint the VA to be contacted for authorization of these services? YES or NO
PUBLIC HEALTH SERVICE
4. Are the services covered by a public health service? YES or NO
If Yes, what is the name of the public health service?
What is the address?
City? State? Zip?
What is the date of the services covered by the public health service?
SNF does not participate in PHS
ACCIDENT
5. Are these services the result of an accident? YES or NO
If Yes, what type of accident was this (For example: Auto, slip and fall [please list location of accident],
malpractice, product liability, homeowners)? -
Is non-liability insurance available (For example: Premises medical, auto medical coverage,
no-fault, homeowners premises)? YES or NO
If Yes, what is the name of the insurance company?
What is the address?
City? State? Zip?
What was the date of the accidentlinjury?
Who is listed as the insured?
20
ACCIDENT(CONTLNUED)
5A. Does the patient feel someone else is responsible for the accidentlinjury? YES or NO I "
If Yes, What is the name of the patient's attorney or the responsible party's insurance company?
What is the address?
City? State? Zip?
What is the name of the responsible insured parry?
EMPLOYER GROUP HEALTH PLAN
,
6. Is the patient covered by any employer group health plan (EGHP), including the Federal Employee Health Benefits YES or NO
or Retirement Policies? If No, this questionnaire is complete. If YES, CONTINUE.
WORKING AGED
7. Is the patient 65 years or older? YES or NO
If Yes, is the patient and/or spouse currently employed by an employer of 20 or more employees? YES or NO
If Yes, is the patient covered by that employer group health plan (EGHP)? YES or NO
If Yes, what is the name of the EGHP?
What is the address?
City? State? Zip?
If the Beneficiary is no longer employed, please give a retirement date if possible:
If the spouse is no longer employed, please give a retirement date if possible:
DISABILITY
8. Is the patient under the age 65? YES or NO
If Yes, is the patient entitled to Medicare solely due to a disability other than end stage renal disease? YES or NO
If Yes, is the patient or family member currently employed by an employer of 100 or more employees? YES or NO
If Yes, is the patient covered by that large group health plan (LGHP)? YES or NO
If Yes, what is the name of the LGHP?
What is the address?
City? State? Zip?
END STAGE RENAL DISEASE(ESRD)
9. Is the patient covered by any EGHP through a current or former employer of any size? YES or NO
Name of group health plan:
Mailing address:
City: State: Zip:
Policy #: Name of policyholder:
Relationship to the patient: Group identification IF:
Name of employer:
Mailing address:
City: State: Zip:
Is the patient within the 30-month coordination of benefits periods'? YES or NO_
What is the month/year of the first regular dialysis'? (MM/DD/CCY)
Has the patient had a kidney transplant? YES or NO
If yes, date of transplant: (MM/DD/CCY)
DUAL ENTITLEMENT
10. Is the patient entitled to Medicare on the basis of either ESRD and age of ESRD and disability? YES or NO
Was the patient's initial entitlement to Medicare (including simultaneous entitlement) based on ESRD? YES or NO
Does the working aged or MSP disability provision apply (i.e. the GHP primary based on the age or disability entitlement)? YES or NO
Note: If Yes to the last question, the GHP remains primary for the 30 month COB period.
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PRIOR STAY INFORMATION I
Has this patient been confined to a hospital or skilled nursing facility within the last 60 days?
If Yes, complete the following information for each stay:
Hospital SNF:
Address:
Admission Date: - Discharge Date: _-
By Whom Verified
MEMO
YES or
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ATTACHMENT F-1
RESIDENT'S PERSONAL TRUST FUND AGREEMENT
The undersigned hereby agree as follows:
1. The Facility shall furnish the Resident with a written receipt for all expenditures and deposits regarding any
of the Resident's funds deposited with the Facility.
2. A record of all transactions regarding the Resident's funds shall be maintained by the Facility in accordance
with generally accepted accounting principles.
3. The Resident shall have access, at any time upon request, to the above record and shall receive an itemized
quarterly statement of his/her account.
4. The Facility has a surety bond to guarantee the Resident's funds.
5. All Resident personal funds are kept in separate account(s) from the Facility operating accounts.
6. The Facility may keep Fifty and 00/100 Dollars ($50.00) or less in a non-interest bearing or petty cash fund
for the Resident's account. Any money in excess of Fifty and 00/100 Dollars ($50.00) will be put in an interest-bearing
account, with the interest to be credited to the Resident.
7. The Resident acknowledges that, upon his/her discharge or death, the balance of his/her account will be
promptly released to the private party or public agency required by law.
8. The Resident authorizes the Facility to distribute or return the Resident's money only to the Resident or the
Resident's designated representative upon written request.
9. The Facility has no duty to invest the money in the Resident's account to earn income other than interest in a
bank checking or similar account, or to accept a deposit that would cause the balance in the Resident's account to exceed
applicable limits of federal or state law.
10. If the Resident receives Medicaid benefits, the Facility shall notify the Resident when the amount in his/her
account reaches Two Hundred and 00/100 Dollars ($200.00) less than the social security income ("SSI") resource limit
for one person and that, if the amount in the account, in addition to the value of the Resident's other nonexempt
resources, reaches the SSI resource limit for one person, the Resident may lose eligibility for Medicaid or SSI.
I have received the Facility's policies on Resident's Personal Trust Fund Accounts and have had the opportunity to read
the information.
[ ] I accept the opportunity to deposit funds within the Center.
[t•3? I decline the opportunity to deposit funds within the Center.
Date: `, -f?`? •~??-?
Resident ( gnature)
Representative (Sign e) Responsible Party (Signature)
Resident Name: Hinds, Hazel S
ATTACHMENT F-2
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ATTACHMENT G-1
HCR MANOR CARE
REFUSAL OF LIFE-SUSTAINING TREATMENT
HCR Manor Care Centers are dedicated to supporting the resident to attain or maintain
his or her highest level or physical, mental, and psychosocial well-being, in accordance with the
resident's personal assessment, his or her individualized Plan of Care, and the resident's wishes
as to medical treatment. The resident's condition, however, may lead him or her to desire to
limit the treatment provided by the Center. In such event, HCR Manor Care Centers will honor
the requests of the resident to refuse life-prolonging treatment, provided that such refusals are
done in accordance with HCR Manor Care's policies. These policies are designed to protect
each resident's rights by following applicable state law governing who can legally consent to
refuse treatment and requiring that the medical record reflect that any other applicable legal
requirements have been satisfied.
HCR MANOR CARE POLICY
HCR MANOR CARE'S policy is to provide all treatment which is medically necessary
to sustain the resident's life, unless a valid order to refuse such treatment is entered in the
resident's medical record by his or her attending physician, in accordance with HCR Manor
Care's Limited Treatment Policy or Policy on "Do Not Resuscitate Orders" ("DNR "),
whichever may be applicable.
Understanding Limited Treatment
HCR Manor Care follows applicable federal and state laws governing the rights of a
resident, whether competent or incompetent, to refuse unwanted medical treatment. An
incompetent resident can direct care through an "advance directive" under applicable state law.
A growing number of states also permit family members to act as "surrogate decision makers" in
the absence of an advance directive. Duly empowered legal guardians might also be permitted to
refuse life-sustaining treatment under applicable state law. Because the laws of each state are
unique, HCR Manor Care has a Limited Treatment Policy for each state. A summary of this
State's laws on advance directives and surrogate decision making is contained in the admissions
packet.
The Limited Treatment Policy imposes procedural requirements for refusing life-
sustaining medical treatment such as mechanical breathing, kidney dialysis, chemotherapy,
blood transfusions, and artificial nutrition and hydration supplied intravenously or through
gastric or nasogastric feeding tubes. Antibiotics might be refused if they are not needed to
alleviate pain and the safety of others in the Center is not threatened.
Whether or not to refuse treatment is a decision to be made by the resident and/or
Responsible Party based upon the advice of the attending physician. HCR Manor Care
recommends that the resident's decisions on the various treatment options be stated with as much
specificity as possible. It is also recommended that the resident execute advance directives and,
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4
if a durable power of attorney for health care is executed, that the resident discuss his or her
wishes in detail with the designated person.
Understanding CPR
CPR is emergency medical procedure used in an attempt to restore circulation and
respiration, which have ceased. The cessation of circulation and respiration is referred to as a
cardiopulmonary arrest. It may take several minutes from the onset of a cardiopulmonary arrest
to the point when the condition becomes irreversible. This time interval may represent a
"window of opportunity" when CPR may be effective in restoring circulation and respiration.
CPR consists of both basic and advanced life support procedures. Basic CPR involves rescue
breathing and chest compressions. Rescue breathing is performed mouth-to-mouth or by using a
special mask and bag. Chest compression, or external cardiac massage, is the compression of the
chest at the lower part of the sternum with one's hands, using the weight of one's body for
pressure. It is done to force the circulation of blood through vital organs.
According to reputable industry studies, CPR has significant limitations. It may fail to
restore circulation or respiration. Even if CPR results in the avoidance of death by the traditional
definition, it may be too late to prevent brain damage. Additionally, circulation and respiration
may be restored in time to preserve brain function, but administration of CPR may fracture ribs,
lacerate organs, or result in other injuries. The administration of CPR is most likely to be
successful when the resident is relatively young and does not have a debilitating condition.
Center personnel will perform Basic CPR if a resident has a cardiopulmonary arrest
unless a valid physician order has been entered in the resident's medical chart or CPR would be
unsuccessful iir restoring cardiac and respiratory function.
Advanced CPR involves higher technology and will be administered only by paramedics called
to the Center to administer such procedures and to transport the resident to the hospital.
26
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ATTACHMENT G2
LIMITED TREATMENT POLICY - PENNSYLVANIA
HCR Manor Care's policy is that all residents will be provided health care unless the
attending physician enters a contrary order in the resident's medical record. The Center will
act to maintain human life in accordance with accepted standards of ethical practice. Health
care will be withheld only in accordance with the procedures set forth in HCR Manor Care's
Limited Treatment Policy for Pennsylvania, which is summarized below.
Competent Resident
A competent resident can refuse medical treatment, including artificial nutrition and
hydration, at any time. The attending physician must, however, record complete information in
the resident's medical record to demonstrate that the decision to refuse treatment was made on
the basis of informed consent.
Incompetent Resident
Pennsylvania law permits decisions to be made on behalf of an incompetent resident in
several ways.
1. Declaration.
If when competent, the resident has executed a living will (known in Pennsylvania as a
"Declaration") in accordance with Pennsylvania law, then life-sustaining treatment can be
withheld in accordance with the resident's instructions set forth in the declaration provided that
the following requirements are met:
a. The attending physician determines that the resident is incompetent;
1?. The procedure of treatment proposed to be withheld is consistent with the
specific instructions, if any, of the resident set forth in the Declaration;
c. The attending physician certifies in the medical record that the resident is
either in a terminal condition or is in a state of permanent unconsciousness;
and
d. The attending physician arranges for the physical examination and
confirmation of the terminal condition or state of permanent unconsciousness
by a second physician. If the resident in his or her Declaration designated a
surrogate to make decisions under these circumstances, then the consent of
such surrogate will also be required.
Artificial nutrition and hydration can only be withheld if all of the foregoing
requirements have been met and the Declaration specifically provides for the withholding of
artificial nutrition and hydration.
e. Durable Power of Attorney and no Declaration.
The Pennsylvania Durable Power of Attorney Act authorizes consent for medical
treatment, but does not specifically authorize the withholding of life-sustaining treatment.
Therefore, unless there is a court order providing otherwise, HCR Manor Care may not honor a
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durable power of attorney for health care. Any such document will be forwarded to the Legal
Department for review.
2. Legal Guardian.
Pennsylvania law may permit a legal guardian to authorize the withholding of life-
sustaining treatment. The scope of the guardian's authority will be verified by the court
documents which appointed the guardian.
3. Close Family Member and Persistent Vegetative State.
If the resident did not executive a valid Declaration or Durable Power of Attorney, or if
the resident does not have a legal guardian with authority to refuse life-sustaining treatment, then
Pennsylvania law permits a family member who is sufficiently close to the resident to render a
judgment on his or her behalf to refuse life-sustaining treatment for a resident who is determined
by two qualified physicians to be in a "persistent vegetative state," provided that there is no
dispute among family members.
Additionally the attending physician must record complete information in the resident's
medical record to demonstrate that the decision of the Responsible Party to refuse treatment was
made on the basis of informed consent and that all other federal and state law requirements have
been satisfied.
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ATTACHMENT H
PRIVACY ACT STATEMENT-HEALTH CARE RECORDS
THIS FORM PROVIDES YOU THE ADVICE REQUIRED BY THE PRIVACY ACT
OF 1974. THIS FORM IS NOT A CONSENT TO RELEASE OR USE HEALTH CARE
INFORMATION PERTAINING TO YOU.
1. AUTHORITY FOR COLLECTION OF INFORMATION INCLUDING SOCIAL
SECURITY NUMBER (SSN)
Sections 1819(f), 1919(f), 1819(b)(3)(A), 1919(b)(3)(A), and 1864 of the Social Security Act.
Skilled nursing facilities for Medicare and Medicaid are required to conduct comprehensive,
accurate, standardized, and reproducible assessments of each resident's functional capacity and
health status. As of June 22, 1998 all skilled nursing and nursing facilities are required to
establish a database of resident assessment information and to electronically transmit this
information to the State. The State is then required to transmit the data to the federal Central
Office Minimum Data Set (MDS) repository of the Health Care Financing Administration.
These data are protected under the requirements of the Federal Privacy Act of 1974 and the
MDS Long Term Care System of Records.
2. PRINCIPAL PURPOSES FOR WHICH INFORMATION IS INTENDED TO BE USED
The information will be used to track changes in health and functional status over time for
purposes of evaluating and improving the quality of care provided by nursing homes that
participate in Medicare or Medicaid. Submission of MDS information may also be necessary
for the nursing homes to receive reimbursement for Medicare services.
3. ROUTINE USES
The primary use of this information is to aid in the administration of the survey and
certification of Medicare/Medicaid long term care facilities and to improve the effectiveness
and quality of care given in those facilities. This system will also support regulatory,
reimbursement, policy, and research functions. This system will collect the minimum amount
of personal data needed to accomplish its stated purpose.
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The information collected will be entered into the Long Term Care Minimum Data Set (LTC
MDS) system of records, System No. 09-70-1516. Information from this system may be
disclosed, under specific circumstances, to: (1) a congressional office from the record of an
individual in response to an inquiry from the congressional made at the request of that
individual; (2) the Federal Bureau of Census; (3) the Federal Department of Justice; (4) an
individual or organization for a research, evaluation, or epidemiological project related to the
prevention of disease of disability, or the restoration of health; (5) contractors working for
HCFA to carry out Medicare/Medicaid functions, collating or analyzing data, or to detect fraud
or abuse; (6) an agency of a State government for purposes of determining, evaluating and/or
assessing overall or aggregate cost, effectiveness, and/or quality of health care services
provided in the State; (7) another Federal agency to fulfill a requirement of a Federal statute
that implements a health benefits program funded in whole or in part with Federal funds or to
detect fraud or abuse; (8) Peer Review Organizations to perform Title XI or Title XVIII
functions, (9) another entity that makes payment for or oversees administration of health care
services for preventing fraud or abuse under specific conditions.
4. WHETHER DISCLOSURE IS MANDATORY OR VOLUNTARY AND EFFECT ON
INDIVIDUAL OF NOT PROVIDING INFORMATION
For nursing home residents residing in a certified Medicare/Medicaid nursing facility the
requested information is mandatory because of the need to assess the effectiveness and quality
of care given in certified facilities and to assess the appropriateness of provided services. If a
nursing home does not submit the required data it cannot be reimbursed for any
Medicare/Medicaid services.
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ATTACHMENT I-1
NOTICE OF INFORMATION PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE
USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS
INFORMATION. PLEASE REVIEW THIS DOCUMENT CAREFULLY.
We have summarized our responsibilities and your rights on this first page. For a complete
description of our information practices, please review this entire notice.
Our Responsibilities
We are required to:
Maintain the privacy of your health information;
Provide you with this notice of our legal duties and information practices with respect
to information we collect and maintain about you; and
Abide by the terms of this notice.
Your Rights
You have several rights with regard to your health information. Those include the right to:
¦ Request that we not use or disclose your health information in certain ways;
¦ Request to receive communications in an alternative manner or location;
¦ Access and obtain a copy of your health information;
¦ Request an amendment to your health information; and
¦ An accounting of disclosures of your health information;
We reserve the right to change our information practices and to make the new provisions
effective for all health information we maintain. Should our privacy practices change, we will
post the changes in a physical place within our building and on our web site. A copy of the
revised notice will be available after the effective date of the changes upon request.
We will not use or disclose your health information without your authorization, except as
described in this notice.
If you have questions and would like additional information, you may contact Randy Holtry,
NHA. 717-263-0436.
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Entities Covered Under This Notice
Manor Care, Inc. through its operating group HCR Manor Care, is the owner and operator of several
entities which operate primarily under the Heartland, ManorCare, and Arden Court names. The following
entities are part of an organized health care arrangement:
¦ Skilled Care Facilities - provide comprehensive health care around the clock by experienced
professionals.
¦ Assisted Living Facilities - provide personal care assistance as needed for dressing, bathing, meal
preparation and medication management for residents who live independently.
¦ Rehabilitation Companies - provide in-patient and out-patient therapy services for those
recovering from illnesses, injuries, or disabilities.
¦ Home Health Care - provide health care in the home so that patients may stay at home while
receiving needed care to function.
¦ Hospice Services - provide hospice services to assist those dealing with terminal illness.
¦ Medicare Part B Provider - Provides certain medical products for eligible individuals.
¦ Pharmacy Products and Services - provide pharmaceuticals to patients who need pharmacy
services.
¦ Physician Services - provide management services to physician practices.
These entities are all affiliated with the same parent company, Manor Care, Inc. The entities participating
in the organized health care arrangement will share health information with each other as necessary to
carry out treatment, payment, or health care operations. Each entity will abide by the terms of this notice
with respect to protected health information received by another participating entity.
Understanding Your Health Record
Each time you visit a medical provider, a record of your visit is made. Typically, this record contains
your symptoms, examination and test results, diagnoses, treatment, and a plan for future care or treatment.
This information, often referred to as your health or medical record, serves the following purposes:
Basis for planning your care and treatment
Communication among health professionals involved in your care
Legal document describing the care you received
Proof that services billed were actually provided
A tool to educate health professionals
A source of data for medical research
A source of information for public health officials who oversee the delivery of health care in the United
States
A tool to measure and improve_the care we give
Understanding what is in your record and how your health infonnation is used helps you to:
Ensure its accuracy
Understand who, what, when, where, and why others may access your health information
Make informed decisions when authorizing disclosure to others.
How We Will Use or Disclose Your Health Information.
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For Treatment. We will use and disclose your personal health information in providing you with
treatment and services. We may disclose your personal health information to personnel who may be
involved in your care, such as physicians, nurses, nurse aides, physical therapists, dietary and admissions
personnel. For example, a nurse caring for you will report any change in your condition to your
physician. We also may disclose personal health information to individuals who will be involved in your
care after you leave the facility.
For Payment. We may use and disclose your personal health information so that we can bill and receive
payment for the treatment and services you receive. For billing and payment purposes, we may disclose
your personal health information to your representative, an insurance or managed care company,
Medicare, Medicaid or another third party payer. For example, we may contact Medicare or your health
plan to confirm your coverage or to request prior approval for a proposed treatment or service.
For Health Care Operations. We may use and disclose your personal health information for our regular
health operations. These uses and disclosures are necessary to manage our operations and to monitor our
quality of care. For example, we may use personal health information to evaluate our services, including
the performance of our staff. We may use a photograph of you to identify you or for general programs
such as posting on activity boards.
Business Associates. Outside people and entities provide some services for us. Examples of these
"business associates" include our accountants, consultants and attorneys. We may disclose your health
information to our business associates so that they can perform the job we've asked them to do. We
require the business associates to safeguard your information so that it is protected.
Directory. Unless you notify us that you object, we may use your name, location in the facility, general
condition, and religious affiliation for directory purposes. We may release information in our directory,
except for your religious affiliation, to people who ask for you by name. We may provide the directory
information, including your religious affiliation, to any member of the clergy.
Notification. We may use or disclose information to notify or assist in notifying a family member,
personal representative, or another person responsible for your care, of your location and general
condition. If we are unable to reach your family member or personal representative, then we may leave a
message for them at the phone number that they have provided us, e.g. on an answering machine.
Communication with Family. We may disclose to a family member, other relative, close personal friend
or any other person involved in your health care, health information relevant to that person's involvement
in your care or payment related to your care.
Bulletin Boards/Newsletters. We may post your name and birth date on a facility bulletin board or in a
facility newsletter.
Research. We may disclose information to researchers when certain conditions have been met.
Transfer of Information at Death. We may disclose health information to funeral directors, medical
examiners, and coroners to carry out their duties consistent with applicable law.
Organ Procurement Organizations. Consistent with applicable law, we may disclose health information
to organ procurement organizations or other entities engaged in the procurement, banking, or
transplantation of organs for the purpose of tissue donation and transplant.
Marketing. We may contact you regarding your treatment, to coordinate your care, or to direct or
recommend alternative treatments, therapies, health care providers or settings. In addition, we may
contact you to describe a health-related product or services that may be of interest to you, and the
payment for such product or service.
Fund raising. We may contact you as part of a fund-raising effort.
Food and Drug Administration (FDA).We may disclose to the FDA, or to a person or entity subject to the
jurisdiction of the FDA, health information relative to adverse events with respect to food, supplements,
33
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product and product defects, or post marketing surveillance information to enable product recalls, repairs,
or replacement.
Worker's compensation. We may disclose health information to the extent authorized by and to the
extent necessary to comply with laws relating to workers' compensation or other similar programs
established by law.
Public health. As required by law, we may disclose your health information to public health or legal
authorities charged with preventing or controlling disease, injury, or disability.
Correctional institution. Should you be an inmate of a correctional institution, we may disclose to the
institution or agents thereof health information necessary for your health and the health and safety of
other individuals.
Law enforcement. We may disclose health information for law enforcement purposes as required by law
or in response to a valid subpoena.
Reports. Federal law allows a member of our work force or a business associate to release your health
information to an appropriate health oversight agency, public health authority or attorney, if the work
force member or business associate believes in good faith that we have engaged in unlawful conduct or
have otherwise violated professional or clinical standards and are potentially endangering one or more
patients, workers or the public.
Your Health Information Riehts
You have the following rights regarding your personal health information:
Right to Request Restrictions. You have the right to request restrictions on our use or disclosure of your
personal health information for treatment, payment or health care operations. You also have the right to
restrict the personal health information we disclose about you to a family member, friend or other person
who is involved in your care or the payment for your care.
We are not required to agree to your requested restriction (except that while you are competent you may
restrict disclosures to family members or friends). If we do agree to accept your requested restriction, we
will comply with your request except as needed to provide you emergency treatment.
Right of Access to Personal Health Information. You have the right to inspect and obtain a copy of your
medical or billing records or other written information that may be used to make decisions about your
care, subject to some limited exceptions. Such records will be provided to you in the time frames
established by law. We may charge a reasonable fee for our costs in copying and mailing your requested
information.
We may deny your request to inspect or receive copies in certain limited circumstances. If you are denied
access to personal health information, in some cases you will have a right to request review of the denial.
Right to Request Amendment. If you believe that any health information in your record is incorrect or if
you believe that important information is missing, you may request that we correct the existing
information or add the missing information. Such requests must be made in writing, and must provide a
reason to support the amendment.
We may deny your request for amendment in certain circumstances. If we deny your request for
amendment, we will give you a written denial including the reasons for the denial and the right to submit
a written statement disagreeing with the denial.
Right to an Accounting of Disclosures. You have the right to request an "accounting" of our disclosures
of your personal health information. This is a listing of certain disclosures of your personal health
information made by the us or by others on our behalf, but does not include disclosures for treatment,
payment and health care operations or certain other exceptions.
To request an accounting of disclosures, you must submit a request in writing, stating a time period
beginning after April 13, 2003 that is within six years from the date of your request. An accounting will
include, if requested: the disclosure date; the name of the person or entity that received the information
34
and address, if known; a brief description of the information disclosed; a brief statement of the purpose of
the disclosure or a copy of the authorization request; or certain summary information concerning multiple
similar disclosures. The first accounting provided within a 12-month period will be free; for further
requests, we may charge you our costs.
Right to a Paper Copy of This Notice. You have the right to obtain a paper copy of this Notice, even if
you have agreed to receive this Notice electronically. You may request of copy of this Notice at any time.
Right to Request Confidential Communications. You have the right to request that we communicate with
you concerning personal health matters in a certain manner or at a certain location. For example, you can
request that we contact you only at a certain phone number. We will accommodate your reasonable
requests.
Right to Revoke Authorization. You may revoke an authorization to use or disclose health information,
except to the extent that action has already been taken. This request must be made in writing.
For More Information or to Report a Problem
If you believe that your privacy rights have been violated, you may file a complaint in writing with us or
with the Office of Civil Rights in the U.S. Department of Health and Human Services. To file a
complaint with us, contact Randy Holtry, NHA. 717-263-0436. We will not retaliate against you if
you file a complaint.
If you have any questions about this Notice or would like further information concerning your privacy
rights, please contact Randy Holtrv, 717-263-0436.
Effective Date: April 14, 2003
35
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ATTACHMENT I-2
RECEIPT OF NOTICE OF INFORMATION PRACTICES
Resident's Name: Hinds, Hazel, S
I acknowledge receipt of HCR Manor Care's Notice of Information Practices.
I V agree ^ object to including Hinds, Hazel, S location in the facility, general condition and
religious affiliation (available to clergy only) in the Facility Directory.
I ? agree object to disclosure of Hinds, Hazel, S health information to a family member or
close personal friend, including clergy, who is involved in my care.
Name (please Print) 1 Sigr #CW
5e.,Vp Las-oy
Relationship to Resident Date
To be completed by Facility Personnel
r
A good faith effort was made to obtain written acknowledgement of the Notice of Information
Practices.
Written acknowledgment was obtained
_ Written acknowledgment was not obtained. Efforts to obtain receipt and reason not
obtained are described below.
Coml leted b ,
Namev? Pnature[ Date
36
ATTACHMENT J
ASM
Ancillary Services Management, Inc.("ASM") is a national Medicare Part B provider and
may have an agreement with this facility to provide certain medical products for eligible
nursing home residents. ASM provides the following: nutritional supplies for tube
feeding, foley catheters for urological patients, surgical dressing supplies, orthotics, as
well as ostomy and tracheostomy supplies for those patients who require them.
If ASM is available in the facility, the resident and/or responsible party selects ASM to
provide Medicare Part B supplies ordered by the resident's attending physician.
The resident and/or responsible party request that Medicare benefits be paid directly to
ASM for any medical supplies provided to the resident which are covered under Medicare
Part B and authorize ASM to bill and collect for such medical supplies directly from
Medicare or other third party payor.
The Resident and/or Responsible Party further authorize any holder of medical information about the
resident to release to the third party payor(s) and its agents any information needed to determine these
benefits.
Date Resident gnature
Date Signature of Responsible Party
37
}
' ATTESTATION OF ADMISSION AGREEMENT AND ATTACHMENT
I jV11 L-,? , on behalf of the Center HCR ManorCare-
Chambersbu
Name Center
certify, as indicated by my initials set forth below, that I have provided the Resident
and/or Responsible Party of Hinds, Hazel S with the Admission Agreement and each of
the attachments listed below. I also acknowledge that I have reviewed each of the
attachments with the Resident and/or Responsible Party, that the Resident and/or
Responsible Party have had the opportunity to ask questions and have had all of their
questions answered satisfactorily. The Resident and/or Responsible Party have signed
each of the required documents in my presence indicating receipt and understanding.
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 and/or 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-1 and F-2.
__6 e. Center Supplement:
1. Policy and procedure on bedholds, election of bedholds 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 unit.
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 certification agency
concerning resident abuse, neglect, mistreatment and
misappropriation of property.
Af. The Resident Handbook.
g. Resident/Patient Rights.
_kjh. Medicare/Medicaid information and display of such information including
how to apply for and use Medicare and Medicaid benefits, and how to
receive refunds for previous payments.
38
K t
i. Receipt of information on advance directives including a copy of "Refusal
of Life Sustaining Treatment", which summarizes HCR 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-1 and G-2.
-LJ. Privacy Act Notification. See Attachment H.
_Lk. Notice of Information Practices and Receipt of Notice of Information
Practices. See Attachments I-1 and I-2.
1. Ancillary Services Management Form. See Attachment J.
I have requested that the Resident and /or the Responsible Party provide the following
documents as applicable:
_a. Copy of Medicare Card for file.
b. Copy of Medicaid Card for file.
"c. Copy of Social Security Card for file.
d. Copy of all insurance cards for file.
e Copy of Prescription Card for file. Note: please copy both sides of card.
f. Copy of Living Will for file.
g. Copy of Health Care and Financial Power of Attorney for file.
---'h. Copy of Guardianship or Health Care Surrogate papers for file.
Name Date
39
E
r '
DURABLE POWER OF ATTORNEY
NOTICE
THE PURPOSE OF THIS POWER OF ATTORNEY IS TO GIVE THE PERSON YOU DESIGNATE
(YOUR " AGENT'S BROAD POWERS TO HANDLE YOUR PROPERTY, WHICH MAY INCLUDE
POWERS TO SELL OR OTHERWISE DISPOSE OF ANY REAL OR PERSONAL PROPERTY
WITHOUT ADVANCE NOTICE TO YOU OR APPROVAL BY YOU.
THIS POWER OF ATTORNEY DOES NOT IMPOSE A DUTY ON YOUR AGENT TO EXERCISE
GRANTED POWERS, BUT WHEN POWERS ARE EXERCISED, YOUR AGENT MUST USE DUE
CARE TO ACT FOR YOUR BENEFIT AND IN ACCORDANCE WITH THIS POWER OF
ATTORNEY.
YOUR AGENT MAY EXERCISE THE POWERS GIVEN HERE THROUGHOUT YOUR LIFETIME,
EVEN AFTER YOU BECOME INCAPACITATED, UNLESS YOU EXPRESSLY LIMIT THE
DURATION OF THESE POWERS OR YOU REVOKE THESE POWERS OR A COURT ACTING ON
YOUR BEHALF TERMINATES YOUR AGENT'S AUTHORITY.
YOUR AGENT MUST KEEP YOUR FUNDS SEPARATE FROM YOUR AGENT'S FUNDS.
A COURT CAN TAKE AWAY THE POWERS OF YOUR AGENT IF IT FINDS YOUR AGENT IS
NOT ACTING PROPERLY.
THE POWERS AND DUTIES OF AN AGENT UNDER A POWER OF ATTORNEY ARE
EXPLAINED MORE FULLY IN.20 PA. C.S. CH. 56.
IF THERE IS ANYTHING ABOUT THIS FORM THAT YOU DO NOT UNDERSTAND, YOU
SHOULD ASK A LAWYER OF YOUR OWN CHOOSING TO EXPLAIN IT TO YOU.
I HAVE READ OR HAD EXPLAINED TO ME THIS NOTICE AND I UNDERSTAND ITS
CONTENTS.
HAZELS HINDS 06/30/2004
[Name], Principal Date
KNOW ALL MEN BY THESE PRESENTS THAT:
L HAZEL, S HINDS: 848514EWBURG RD NEWBURG PA 172409711
(Insert your name and address)
do hereby appoint:
CHRISTOPHER A HINDS: 39 LARCH DR SHIPPENSBURG PA 17257
(if one person is to be appointed your Agent, insert the name and address of your agent above)
(if 2 or more persons are to be appointed your Agents, insert their names and addresses above)
WPA034 (04104)
H1B
EXHIBIT "B"
my true and lawful Agent(s) to act
(If more than one Agent is appointed, choose one of the following two choices by writing your initials in
one of the blank spaced below to the left of your choice; if you fail to indicate a choice by not initialing
either of the blank spaces below, your appointed Agents will be required to act together with respect to
the powers granted in this Durable Power of Attorney.)
Each Agent may act alone
All Agents must act together
in my name, place and stead, and on my behalf, with the fullest possible powers; to engage m transactions
with MANUFACTURERS AND TRADERS TRUST COMPANY and its affiliates and subsidiaries
(hereinafter collectively referred to as "M&T Bank") with respect to the following matters indicated
below, with the same powers and for all purposes with the same validity as I could do if I was personally
present:
I. GENERAL POWERS:
(DIRECTIONS: Initial in the blank space to the left of your choice any one or more of
the following lettered subdivisions as to which you want to give your agent authority. if
the blank space to the left of any particular lettered subdivision is not initialed, no
authority will be granted for matters that are included in that subdivision finless you
follow the alternate procedure described in the next sentence. Alternatively, the letter
corresponding to each power you wish to`grant may be written or typed on the blank line
in subdivision "D" and you may them put your initials in the blank space to the left of
subdivision "D" in order to grant each of the powers as indicated. Please note that your
grant of powers in a lettered subdivision gives'your Agent(s) authority over all matters
described in that lettered subdivision, including, where applicable, all matters that are
described in any numbered paragraphs that are part of such lettered subdivision.)
s, lei A. To engage in banking and financial transactions with M&T Bank as follows:
To sign checks, drafts, orders, notes, bills of exchange ind other instruments
("items") or otherwise make withdrawals, by auy medium made available for
such purpose by M&T Bank, from checking, negotiable order of withdrawal,
savings, money market, certificate of deposit or other deposit accounts in my
name and endorse items payable to me and receive the proceeds in cash or
otherwise;
2. To ppen and close all kinds of deposit accounts with M&T Bank in my name,
including checking, negotiable order of withdrawal, savings, money market,
certificate of deposit and other deposit accounts, purchase and redeem savings
certificates, certificates of deposit or similar instruments in my name and execute
and deliver receipts for any funds withdrawn or certificates redeemed;
To deposit funds received for me hi accounts in my name with M&T Bank;
2
4. To request and receive copies of statements, items, tickets and other documents
relating to my accounts at M&T Bank and to pay any charges assessed by M&T
Bank from funds in my accounts; and to change the mailing address on any
accounts of mine at M&T Bank to the Agent's address or such other address as
the Agent determines;
5. To perform all acts and enter into with M&T Bank, execute and acknowledge all
agreements, contracts, writings, assurances, documents and instruments,
including indemnifications, in regard to any and all checking, negotiable order of
withdrawal, savings, money market, certificate of deposit and other deposit
accounts with M&T Bank to the same extent as I could do if personally present;
provided, however, the authority herein granted shall include neither the power to
revoke or change any beneficiary designation made by me with respect to any
deposit account maintained with M&T Bank nor the power to designate a
beneficiary with respect to.any deposit account in my name maintained with
M&T Bank whether now existing or subsequently opened unless I specifically
grant such authority in subdivision II B below;
b: To sign any tax information or reporting form required by Federal, state or local
taxing authorities in regard to any deposit account maintained with or opened at
M&T Bank, including, but not limited to, Internal Revenue Service Form W-9 or
Internal Revenue Service Form:W-8 (or W-8 BEN) or any substitute or similar
form, as applicable.
B: To enter into and to be provided with access to the contents of any safe deposit box
rented in my name from M&T Bank and to add to or remove the contents of such
safe deposit box; to open and close safe deposit boxes rented in my name from
M&T Bank; provided, however, my Agent shall not be authorized by this
Durable Power of Attorney to deposit or keep in any safe deposit box in my
name that is rented from M&T Bank any property in which my Agent shall have
a personal interest.
C. To engage in retirement plan transactions in regard to any Individual Retirement
Account and/or Roth Individual Retirement Account established in my name and
with respect to which M&T Bank is the trustee or custodian as follows:
i . To make contributions (including rollover contributions) to and authorize
distributions from any such Individual Retirement Account or Roth Individual
Retirement Account, as well as to direct M&T Bank as to the investment of funds
therein in such deposit accounts and other investment vehicles available at or
through M&T Bank;
2. To select and change payment options for any Individual Retirement Account
and/or Roth Individual Retirement Account with respect to which M&T Bank is
the trustee or custodian;
To perform all acts and enter into with M&T Bank, execute and acknowledge all
agreements, contracts, writings, assurances, documents and instruments,
including indemnifications, in regard to any Individual Retirement Account
and/or Roth Individual Retirement Account established by me and with respect to
3
y.
which M&T Bank is the trustee or custodian; provided, however, the authority
herein granted shall include neither the power to revoke or change any
beneficiary designation made by me with respect to any such Individual
Retirement Account or Roth Individual Retirement Account nor the power to
designate a beneficiary with respect to any such Individual Retirement Account
or Roth Individual Retirement Account unless I specifically grant such authority
in subdivision H A below.
D. To act with respect to each of the above matters identified by the following
letters: A
H. POWER TO DESIGNATE BENEFICIARIES:
'(DIRECTIONS: Initial in 'the blank space to the left of one or more of the following
lettered and numbered subdivisions IF you wish to give your Agent the power to
revoke, change and designate beneficiaries as described in each subdivision. If you
authorize your Agent to revoke, change and designate beneficiaries under A and/or B
below, you roust also indicate the scope of the Agent's authority by initialing either
option 1 or 2 -wider section A and/or B; as applicable. If you initial subdivision A and/or
B below but fail to initial either option °1 `or 2 of subdivision'A and/or B, your Agent will
have the authority to revoke or change a"beneficiay designation and to designate
beneficiaries other than himself, herself, or any other Agent (if you have appointed more
than one agent herein) but may not name himself, herself, or any other Agent as a
beneficiary:' If your Agent isNOTi Authorized to revoke,- change and designate
beneficiaries, do NOT initial any of the following blank "spaces.)
A. To revoke, change and designate beneficiaries of any Individual Retirement
Account or Roth Individual Retirement Account as follows:
1. Agent is authorized to revoke or change a beneficiary
designation I have made and to designate beneficiaries other than himself,
herself; or any other Agent (if I have appointed more than one agent herein) but
inay not name himself, herself, of any other Agent. as a beneficiary of any
Individual Retirement Account or Roth Individual Retirement Account;
2. Agent is authorized to revoke or chauge a beneficiary
designation I have made and to designate beneficiaries Including himself,
herself, or any other Agent (if I have apl ointed more than one agent herein) as a
beneficiary of any Individual Retirement Account or Roth Individual Retirement
Account.
B. To revoke, change and designate beneficiaries of any deposit account maintained
with M&T Bank whether now existing or subsequently opened (except that my
Agent shall not have such authority with respect to any Individual Retirement
Account or Roth Individual Retirement Account unless I so specify in subsection
II A above), as follows:
4
1. Agent is authorized to revoke or change a beneficiary
designation I have made and to designate beneficiaries other thin himself,
herself, or any other Agent (if I have appointed more than one agent herein) but
may not name himself; herself, or any other Agent as a beneficiary of any deposit
account maintained with M&T Bank, whether now existing or subsequently
opened (except that my Agent shall not have such authority with respect to any
Individual Retirement Account or Roth Individual Retirement Account unless I
so specify in subsection H A above);
2. Agent is authorized to revoke or change a beneficiary
designation I have made and to designate beneficiaries ineludinQ himself,
herself, or any other Agent (if I have appointed more than one agent herein) as F
beneficiary of any deposit account maintained with MBtT Bank, whether now
existing or subsequently opened (except that my Agent shall not have such
authority with respect to any Individual Retirement Account or Roth Individual
Retirement Account unless I so specify in subsection lI A above).
REVOCATION OF PRIOR INCONSISTENT POWERS
By this Durable Power of Attorney, I hereby revoke any power of attorney that I have previously given to
any person with respect to the matters in regard to which this Durable Power of Attorney is granted.
Except to the extent revoked by this Durable Power of Attorney, any power of attorney that I have
previously given to any person with respect to matters that are not covered by this Durable Power of
Attorney shall remain in full force and effect.
DURABLE POWER
This Durable Power of Attorney shall not be affected by my subsequent disability or incapacity nor expire
by reason of the lapse of time.
RATIFICATION OF ACTIONS: MULTIPLE AGENTS
I hereby ratify and confirm all that each Agent acting hereunder shall do or cause
to be done under this Durable Power of Attorney;
2. This Durable Power of Attorney shall be revoked by my giving to such Agent
acting hereunder written notification of the revocation, which notice shall not be
considered binding unless actually received;
If more than one Agent has been appointed by me under this Durable Power of
Attorney under a direction that my appointed Agents are required to act together
in exercising their authority as my Agents, my Agents shall be required, to act
jointly by decision of all Agents designated-'iii fi i'g'.Ddii e- owerif ttorney
who are alive and not under any legal'. disability; and.the signat ire of one or more
Agents without the signature of any other Agemf tianied ih t 4 i_+Sti )e Power of
Attorney shall not be effective to act bn.my.behalf, tiiileas ranch o l e`-' Agent(s) is
(are) deceased or under a legal disability:
aC
i -
INDEMNIFICATION OF M&T BANK
To induce M&T Bank to act on the instructions of my appointed Agent(s) pursuant to the grant of
authority contained in this Durable Power of Attorney, I hereby agree that, upon receiving a copy or
facsimile of this executed instrument, M&T Bafik may act on the instructions of my appointed Agent(s)
and that revocation or termination of this Durable Power of Attorney shall be ineffective as to M&T Bank
unless and until actual notice or kno*ledge of such revocation or termination shall have been received by
M&T Bank, and I, for myself and for my heirs, executots, legal representatives and assigns, hereby agree
to indemnify and hold harmless M&T Bank from and against any and all elgims that may arise against
M&T Bank by reason of M&T Bank's having relied on the provisions of this instrument.
SCOPE OF GRANTED POWERS
The powers herein granted to my appointed Agent(s): (1) mayonly be exercised by my Agent(s) in
connection with transactions with M&T Bank 'and its affiliates and my not be exercised in connection
with transactions with other parties; and (2) may be exercised with respect to my interest in any account
or safe deposit box, including but not limited to any account for which I am sole owner or for which I am
joint account owner with one or more other parties.
RESERVATION OF RIGHT TO REVOIKE
This Durable Power of Attorney may be revoked by me at any time.
IN WITNESS VV11MEOF, and intending to be legally bound, I have hereunto set my hand this
?I7h day of ;?Zk, , 2004
)OU F/
Principal Witness
COMMONWEALTH OF PENNSYLVANIA
COUNTY OF On the day ofao L , before me, a Notary Public, personally appeared
and in due form of law acknowledged the
foregoing Durable Power of Attorney to be his (her) act and deed and desired that the same might be
recorded as such.
WITNESS my hand.and notarial seal.
COMMONWEALTH OF. PENNSYLVANIA
Notarial Seal
A" L AK Notary PLac
Chonb0bug Wo, FinarW Cowty
My Oarrnleelon Eapkes A" 21, 2008 ..
MWmbar, Pennsy1-18 A3360agon Of Notar}sS
(Notarial Seal)
Nota Pu is
ACKNOWLEDGMENT BY AGENT (Sl
I, CHRISTOPHER A HINDS have read the foregoing Power of Attorney and am
[the person/one of the persons] identified as (thelan] Agent for the principal. I hereby acknowledge
that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa. C.S., when
I act as Agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from zmy assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal.
Age Date
L have read the foregoing Power of Attorney and am
[the person/one of the persons] identified as [the/an] Agent for the principal. I hereby acknowledge
that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa. C.S., when
I act as Agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from my assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal.
Agent Date
I, have read the foregoing Power of Attorney and am
[the person/one of the persons] identified as [the/an] Agent for the principal. I hereby acknowledge
that in the absence of a specific provision to the contrary in the power of attorney or in 20 Pa. C.S., when
I act as Agent:
I shall exercise the powers for the benefit of the principal.
I shall keep the assets of the principal separate from my assets.
I shall exercise reasonable caution and prudence.
I shall keep a full and accurate record of all actions, receipts and disbursements on behalf of the principal.
Agent
Date
7
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CASE NO: 2006-06208 P
SHERIFF'S RETURN - REGULAR
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANORCARE INC
VS
HINDS CHRISTOPHER A ET AL
BRIAN BARRICK
Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
HINDS CHRISTOPHER A
the
DEFENDANT , at 1838:00 HOURS, on the 1st day of November , 2006
at 39 LARCH LANE
SHIPPENSBURG, PA 17257
was served upon
by handing to
CALVIN HOLESIA, STEP SON
a true and attested copy of COMPLAINT & NOTICE
together with
and at the same time directing His attention to the contents thereof.
Sheriff's Costs: So Answers:
Docketing 18.00
Service 17.60 Postage .39
Surcharge 10.00 R. Thomas Kline
.00
45.99/ 11/02/2006
( l /'Zpgv? OBRIEN BARIC SCHERER
Sworn and Subscibed to By: W /1' 4 VX4
before me this day eputy Sheriff
of A. D.
14. -s
CASE NO: 2006-06208 P
SHERIF'F'S RETURN - REGULAR
COMMONWEALTH OF PENNSYLVANIA:
COUNTY OF CUMBERLAND
HCR MANORCARE INC
VS
HINDS CHRISTOPHER A ET AL
BRIAN BARRICK
Sheriff or Deputy Sheriff of
Cumberland County,Pennsylvania, who being duly sworn according to law,
says, the within COMPLAINT & NOTICE
HINDS LORI
was served upon
the
DEFENDANT , at 1838:00 HOURS, on the 1st day of November , 2006
at 39 LARCH LANE
SHIPPENSBURG, PA 17257
CALVIN HOLESIA, SON
by handing to
a true and attested copy of COMPLAINT & NOTICE together with
and at the same time directing His attention to the contents thereof.
Sheriff's Costs: So Answers:
Docketing 6.00
.00
Service
Affidavit .00
Surcharge 10.00 R. Thomas Kline
.00
16.00s/'11/02/2006
OBRIEN BARIC SCHE R
Sworn and Subscibed to By:
before me this day De t Sheriff
of A. D.
w ?
it
t
HCR MANORCARE, INC.,
Plaintiff,
V.
CHRISTOPHER A. HINDS and
LORI HINDS, husband and wife,
Defendants.
IN THE COURT OF COMMON PLEAS OF
CUMBERLAND COUNTY, PENNSYLVANIA
NO. 2006- 6208 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,
BARIC
David A. Baric, Esquire
I.D. # 44853
Date: August 22, 2007 19 West South Street
Carlisle, PA 17013
(717) 249-6873
Attorney for Plaintiff
dab.dir/manorcare/hinds/discontinue-cumberland2. pra
•.,
CERTIFICATE OF SERVICE
I hereby certify that on August 22, 2007, 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:
Christopher A. Hinds
Lori Hinds
39 Lar Drive
Shippensburg, Pe lvania 17257,
A.
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