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HomeMy WebLinkAbout06-6967Li IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. : D/ B/ A WEST SHORE HEALTH AND REHABILITATION CENTER, ; Plaintiff, V. No. ain DOROTHY SCOTT, Defendant. CIVIL ACTION - EQUITY NOTICE TO DEFEND Pursuant to PA RCP No. 1018.1 YOU HAVE BEEN SUED IN COURT. If you wish to defend against the claims set forth in the following pages, you must take action within twenty (20) days after this complaint and notice are served, by entering a written appearance personally or by attorney and filing in writing with the court your defenses or objections to the claims set forth against you. You are warned that if you fail to do so the case may proceed without you and a judgment may be entered against you by the court without further notice for any money claimed in the complaint or for any other claim or relief requested by the plaintiff. You may lose money or property or other rights important to you. YOU SHOULD TAKE THIS PAPER TO YOUR LAWYER AT ONCE. IF YOU DO NOT HAVE A LAWYER, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW. THIS OFFICE CAN PROVIDE YOU WITH INFORMATION ABOUT HIRING A LAWYER. IF YOU CANNOT AFFORD TO HIRE A LAWYER, THIS OFFICE MAY BE ABLE TO PROVIDE YOU WITH INFORMATION ABOUT AGENCIES THAT MAY OFFER LEGAL SERVICES TO ELIGIBLE PERSONS AT A REDUCED FEE OR NO FEE. Cumberland County Bar Association -- ------ -- .....--.32- South Bedford Street Carlisle, PA 17013 Telephone: (717) 249-3166 ORIGINAL r EN LA CORTE DE ALEGATOS COWN DEL CONDADO DE CUMBERLAND, PENNSYLVANIA BEVERLY ENTERPRISES, INC. ; D/B/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, ; V. No. DOROTHY SCOTT, Defendant. CIVIL ACTION - EQUITY AVISO PARA DEFENDER Conforme a PA RCP Num. 1018.1 USTED HA SIDO DEMANDADO/A EN CORTE. Si usted desea defenderse de las demandas que se presentan mas adelante en las siguientes paginas, debe tomar accion dentro de los proximos veiente (20) dias despues de la notificacion de esta Demanda y Aviso radicando personalmente o por medio de un abogado una comparecencia escrita y radicando en la Corte por escrito sus defensas de, y objeccionee a, las demandas presentadas aqui en contra suya. Se le advierte de que si usted falla de tomar accion como se describe anteriormente, el caso puede proceder sin usted y un fallo por cualquier suma de dinero reclamada en la demanda o cualquier otra reclamacion o remedio solicitado por el demandante puede ser dictado en contra suya por la Corte sin mas aviso adicional. Usted pued perder dinero o propiedad u otros derechos importantes para usted. USTED DEBE LLEVAR ESTE DOCUMENTO A SU ABOGADO INMEDIATAMENTE. SI USTED NO TIENE UN ABOGADO, LLAME O VAYA A LA SIGUIENTE OFICINA. ESTA OFICINA PUEDE PROVEERLE INFORMACION A CERCA DE COMO CONSEGUIR UN ABOGADO. SI USTED NO PUEDE PAGAR POR LOS SERVICIOS DE UN ABOGADO, ES POSIBLE QUE ESTA OFICINA LE PUEDA PROVEER INFORMACION SOBRE A-G- ENCIAS QUE-OFREZC SER`VIelOS LEGAL-ES SIN CARGO- © BAJO EOSTO-* PERSONAS QUE CUALIFICAN: Cumberland County Bar Association 32 South Bedford Street Carlisle, PA 17013 Telefono: (717) 249-3166 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/B/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. DOROTHY SCOTT, Defendant. : No. Q?. 4917 6'1,, j L CIVIL ACTION - EQUITY COMPLAINT AND NOW, COMES, Plaintiff, Beverly Enterprises, Inc. d/b/a West Shore Health and Rehabilitation Center ("Plaintiff"), by and through its attorneys, SCHUTJER BOGAR LLC, and files the following complaint against Dorothy Scott ("Defendant"), and in support thereof, states: 1. Plaintiff, a corporation licensed to do business in the Commonwealth of Pennsylvania, is a skilled nursing care provider with its principal offices located 770 Poplar Church Road, Camp Hill, Pennsylvania 17011. 2. Defendant is an adult individual who currently resides at 242 Woodbine Street, Harrisburg, Pennsylvania 17110. 3. On or about February 16, 2006, Defendant made application on behalf of her mother, Gertrude Freeman ("Ms. Freeman"), for admission to Plaintiff's skilled nursing facility. 4. On or about February 16, 2006, Plaintiff and Defendant entered into a written Admission Agreement ("Agreement"), pursuant to which Plaintiff agreed to provide Ms. Freeman with skilled nursing care and services in return for Defendant's promise, as resident's representative, to make payment for that skilled nursing care and services from Ms. Freeman's resources, or, upon Ms. Freeman becoming insolvent, to make timely and proper application for Medical Assistance benefits on behalf of Ms. Freeman and to provide all of the necessary documentation for an eligibility determination to be made with regarding to Ms. Freeman's application for Medical Assistance benefits. A true and correct copy of the Admission Agreement is attached as Exhibit "A." 5. Shortly after Ms. Freeman's admission to Plaintiff's skilled nursing facility, she allegedly became insolvent. As a result, an application for Medical Assistance benefits was subsequently filed. 6. The application for Medical Assistance benefits was denied on July 26, 2006 because the information needed by the Cumberland County Assistance Office to determine Ms. Freeman's eligibility for Medical Assistance benefits was not provided to the Cumberland County Assistance Office. A true and correct copy of the PA-162 is attached as Exhibit "B." 7. As of October 2006, an outstanding balance of $36,077.58 is owed to Plaintiff for the care and services it has provided to Defendant's mother. 2 8. At all times material hereto, Defendant has not cooperated with the Medical Assistance application process and has not provided the information and documentation necessary for that process. 9. An appeal of the July 26, 2006 denial of the application for Medical Assistance benefits is currently pending before the Bureau of Hearing and Appeals of the Department of Public Welfare of the Commonwealth of Pennsylvania. 10. If the documents requested by the Cumberland County Assistance Office are not provided by Defendant prior to or at the time of the hearing on the appeal, the application for Medical Assistance benefits will ultimately be denied, and any further appeal to the Commonwealth Court would be without merit. COUNT I - BREACH OF CONTRACT/SPECIFIC PERFORMANCE 11. Paragraphs 1 through 10 are incorporated by reference as though restated in full. 12. Plaintiff has provided skilled nursing care and services to Ms. Freeman in accordance with the Agreement attached as Exhibit "A." 13. Defendant has breached the Agreement attached as Exhibit "A" by not cooperating with the Medical Assistance application process and not providing the documentation requested by the Cumberland County Assistance Office for a determination to be made as to the eligibility of Ms. Freeman for Medical Assistance benefits. 3 14. As a result of the failure of Defendant to abide by the terms and conditions of the Agreement, the application for Medical Assistance benefits filed for Ms. Freeman has been denied. 15. The aforementioned breach of the Agreement with Plaintiff has caused and continues to cause irreparable harm to Plaintiff. 16. Upon information and belief, at all times material hereto, Defendant and Ms. Freeman have been financially unable to compensate Plaintiff for the care and services that it has rendered to Ms. Freeman in accordance with the terms and conditions of the Agreement. 17. Accordingly, only a decree of specific performance will adequately protect the interests of Plaintiff and provide it with the benefits and/or protections promised under the Agreement. WHEREFORE, Plaintiff respectfully requests that this Court enter a decree ordering specific performance of the Agreement by the parties. COUNT II -- SPECIFIC PERFORMANCE/STATUTORY DUTY OF SUPPORT 18. Paragraphs 1 through 17 are incorporated by reference as though restated in full. 19. Defendant is the daughter of Ms. Freeman. 20. At all times material hereto, upon information and belief, Ms. Freeman has been indigent. 4 21. At all times material hereto, Defendant has had a statutory duty to financially support her mother. See 23 Pa.C.S. § 4603(a). 22. At all times material hereto, Defendant has failed to financially support her mother. 23. The statutory duty of Defendant to support her mother must reasonably include the duty to assist with securing financial support through the Medical Assistance system and the duty to not actively work against Medical Assistance approval. 24. At all times material hereto, Defendant has failed to care for, maintain or financially assist her mother by refusing to provide the documents requested by the Cumberland County Assistance Office to determine the eligibility of her mother for Medical Assistance benefits. WHEREFORE, Plaintiff respectfully requests that this Honorable Court order Defendant to produce the documentation required for a determination of Gertrude Freeman's eligibility for Medical Assistance benefits, consistent with her duty to secure financial support for her mother. 5 Respectfully submitted, Dated: 8 / 0 SCHUTJER BOGAR LLC ?--- Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 305 N. Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff 6 NOV-21-2006(TUE) 14.44 P. 008/008 VERTFICAxION The undersigned hereby verifies that the statements of fact in the foregoing Complaint are true and correct to the bast of my knowledge, information and belief. I understand that any false statements therein are subject to the penalties contained in 18 Pa. C. S. § 4904, relating to unsworn falsification to authorities. Dated: ) 6 1 1 /--- - 4? Jas n Reever Nursing Home Administrator EXHIBIT "A" Kx uate/Time NOV-06-2006(MON) 11:35 NOV-06-2006 11:30 FROM:eEUERLY HEALTH CARE 717 65197980 717 651979$0 P 006 TO:9095925 P.6,,19 N'El (0!?IE THANK FOU FOR CHOO.SING VV FOR YOUR NURVL'VG ,FA('11,.1TI` CAju- The staff of this Facility will take whatever time is necessary to answer all of your questions about this Agreement. Before signing the Agreement, please continue to ask questions until you believe that you understand the Agreement. 1. NONDISCRIMINATION STATEMENT - The Facility welcomes all persons in need of its services and does not discriminate on the basis of age, disability, .race, color, national origin, ancestry, religion, or sex. The Facility does not discriminate among persons based on their sources of payment. Il. CONSENT FOR TREATMENT A. Nursing Facility Services - By signing this Agreement, the Resident consents to the Facility providing routine nursing and other health care services as directed by the attending physician. From time to time, the Facility may participate in training programs for persons seeking licensure or certification as health care workers. In the course of this participation, care may be rendered to the Resident by such trainees under supervision as required by law. .In addition, the Facility may use outside contractors to assist in providing routine nursing and other health care services. Consent to routine nursing care provided by the Facility shall include consent for care b) such trainees and contractors- B. Physician Services - The Resident acknowledges that he or she is under the medical care of a personal attending physician and that the facility provides services based on the general and specific instructions of this physician. The Resident has a right to select his or her own attending physician. if, however, the Resident does not select an attending physician or is unable to select an attending physician, an attending physician may be designated by the Facility, or in accordance with State law. The Resident recognizes and agrees that all physicians providing services to the Resident; including those designated by the Facility, are independent contractors. The Resident recognizes and agrees that such physicians are not associates or agents of the Facility and that the Facility's liability for any physician's act or omission is limited. The Resident shall be solely responsible for payment of all charges of any physician who renders care to the Resident in the facility, unless the charges are covered by a third party payer. C. Right To Refuse Services - The Resident has the right to refiise treatment and to revoke consent for treatment The Resident also has the right to be informed of the medical consequences of such refusal or revocation of consent, and to be informed of alternate treatments available. Where, in the opinion of the attending physician or by judgment of a court of law, the Resident is determined to be mentally incompetent to make a decision regarding refusal of treatment, the decision to refuse treatment may be made by a Legal Representative or other surrogate decision maker, subject to State and Federal law. M. PHOTOGRAPHS - The Resident agrees to allow the Facility to photograph or videotape the Resident as a means of identification or for health related purposes. The photographs or videotapes may also be used to help locate the Resident in the event of an unauthorized absence from the Facility, but shall otherwise be kept confidential. If the Facility intends to use the photograph or videotape fbr purposes other than those noted above, the Facility shall get written permission from the Resident in advance of such use. The Resident retains the right to refuse the taking of a photograph at any time. IV. ARBITRATION - The. Resident acknowledges that disputes tinder- this Agreement may be submitted to arbitration, if the Resident elects to do so, by sigmi.ng a separate agreement executed rT ttx Uate/Time NOV-06-2006(MON) 11:35 NOV-06-2006 11:30 FROM:BEVERLY HEALTH CARE 717 65197980 717 6519798() P.007 T0:9095925 P.7,,19 between the parties. Agreeing to arbitration is not a condition of ?dmission or continuing care. V. PRIVACY ACT NOTWICA'T OWN STATEMENT - Skillcd nursing facilities who contract with the Medicare and Medical Assistance Programs (hereinafter referred to as "Medical Assistance Program" or "Program") 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 (14D S) rcposito,y of the C'asnters for Medicare and Medicaid Services. These data are protected under the requirements of the Federal Privacy Act of 1974 and MDS Long Term Care Systems of Records. The Center for Medicare and Medicaid Services is authorized to collect these data by Sections 19 t9(f), 1919(f), 1819(b)(3 j(A) and 1864 of the Social Security Act. The purpose of this data collection is to aid in the administration of the survey and certification of Medicare/Medical Assistance long-term care facilities and to study the effectiveness and quality of care liven in those facilities. This system will also support regulatory, reimbursement, policy, and research functions This system will collect the sunimum amount of personal data needed to accomplish its stated purpose. 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, tinder specific circumstances, to., (1) a congressional office tiom the record of an individual in response to an inquiry from the congressional office made at the request of that individual; (2) the Bureau of Census; (3) the Department of Justice; (4) an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, or the restoration of health; (5) analyzing data, or to detect fraud or abuse; (6) an agency of a State Government for effectiveness, and/or duality of health care services provided in the State, (7) another benefits program funded in whole or in part with Federal funds or to detect fraud or abuse; (8) Peer Review Organizations to perform Title X1 or Title XVI1I functions; (9) services for preventing fraud or abuse under specific conditions. You should be aware that P.L. 100-603, the Computer Matching and Privacy Protection Act of 1988, permits the government to verify information by way of computer matches. Collection of the Social Security Number is voluntary; however, failure to provide this information may result in the loss of Medicare benefits. The Social Security Number will be used to verify the association of information to the appropriate individual. For nursing home residents residing in a certified Xedicare/Medical Assistance nursing facility the requested information is mandatory because of the need to assess the efrectiveness 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/Medical Assistance services. V1. RESIDENT'S PERSONAL P'ROPERTV A. Safety Of Resident's Personal Property 11e Facility strongly discourages the keeping of valuable jewelry, papers, large sum3 of money, or other items considered of value in the Facility. 'rhe Facility shall make reasonable efforts to safeguard the Resident's property/valuables, which the Resident chooses to keep in his or her possession. The Resident agrees to inform the Facility in writing ol'all personal property upon admission. If, at any time during the Resident's stay, new items of value are brought to or removed from the Resident's possessions in the Facility, the Resident alxo agrees to so T_ Rx uate/Time NOV-06-2006(MON) 11;35 717 65197980 NOU-06-2006 11:30 FROM:BEVERLY HEALTH CARE 717 65197980 TO:9095925 P 008 ' P.8/19 infi-)rm the Facility Executive Director or designee B. Personal Property Of Resident Upon Discharge - The Facility shall make reasonable efforts to safeguard the Resident's personal belongings after discharge The Facility, however, shall not be liable fir any damag=e to or loss of the Resident's property. The Facility may dispose: of any property left by the Resident if not claimed within thirty (30) days of discharge or transfer, or in accordance with applicable State law VII. PERSONAL, FUNDS A. Right To Manage Own Funds - The Resident has a right to manage his or her own personal funds. If the Resident wants assistance with the management of personal funds, the Facility shall assist if requested to do so in writing. B. Resident Trust Fund Authorization- At the Resident's written request (see Resident Trust Fund Authorization form at the back of this Agreement), the Facility will hold, safeguard, manage and account for these funds. C. Interest - The Facility shall deposit funds in excess of Fifty Dollars ($50.00) in an interest-bearing account insured by the Federal Deposit Insurance Corporation (FDIC) that is separate from any Facility operating accounts. All interest earned on the Resident's funds shall be credited to the Resident's account. The Facility shall have the option of depositing; funds of less than Fifty Dollars ($50.00) in one of the following: a non-interest bearing; account, an interest bearing account, or petty cash fund. The Facility shall inform the Resident as to how his or her funds are being held The Facility's policy is to maintain all Resident funds in a separate account, except for a nominal amount maintained in a petty cash fund for the Resident's convenience D. Accounting; - 7'he facility shall have a system that ensures a complete and separate accounting, based on generally accepted accounting principles, of the personal funds deposited with the Facility by each Resident or on his or her behalf. This system shall also ensure that the Resident's funds are not commingled with the Facility's funds or with any other funds besides those of other Residents In addition to the required quarterly accounting, the Facility shall provide individual financial records at the written request of the Resident E. ]Medical Assistance Residents - The personal fund balances of Residents who receive Medical Assistance Program benefits must remain within a certain dollar range to satisfy State and Federal laws. The Facility shall notify a Medical Assistance Program Resident if his or her account balance is within Two Hundred Dollars ($200.00) of the Federal Supplemental Security Income (SSJ) limit. The Facility shall also notify the Resident if the account balance, in addition to the Resident's known non-exempt assets, reaches the SSI resource limit. A balance in excess of this limit may cause the Resident to lose eligibility for Medical Assistance Or SS1. F. Refunds - If a Resident who has personal funds deposited with the Facility expires, the Facility shall refund the Resident's account balance within thirty (30) days and provide a full accounting of these firnds to the individual, probate jurisdiction administering the Resident's estate, or other entity-or individual, as required by State law or regulation. Upon discharge, the balance of funds in the trust account shall be promptly refunded in accordance with the Facility's Refund Policy that is available for review in the facility's Business Office r%A UCleiilme NOV-06-2006(MON) 11:35 NOV-06-2006 11:31 FROM:9EVERLY HEALTH CARE 717 65197980 717 651979$0 P. 009 70:9095925 P.9/19 G. :Security of Funds - The Facility shall ensure the security of all personal funds deposited with the Facility and shall not take money from a Medicare or Medical Assistance Program Resident's personal funds for any item or service for which payment can be made under the Programs. VIII. 'THE RESIDENT'S DUTIES A. Facility's Rules And Regulations - The Resident agrees that the Facility may, to maintain orderly and economical operations, adopt reasonable rules and regulations to govern the conduct and responsibilities of the Resident. The Resident agrees to follow those rules and regulations and hereby acknowledges that he or she has been given a written copy of such rules and regulations. It is understood that the rules and regulations may be amended from time to time as the Facility may require. Any changes to the rules and regulations shall be given to the Resident in writing. B. Resident Grievances - Residents are urged to bring any grievance concerning the Facility to the attention of the Facility Executive Director or designee. The Facility also offers a toll-free "Hotline" telephone number through which grievances can be registered anonymously. This number is t-800-572- 9981 Residents also have the right to contact the State Facility licensing agency, the long-term care ombudsman, or both, to register grievances against the Facility. C. Diet - The Resident understands that his or her diet is medically prescribed and, therefore, must be monitored by the Facility. The Resident agrees to consult with Nursing or Dietary staff regarding food or beverages brought into the Facility for the Resident's benefit. D. Medications - No medications or drugs may be brought upon Facility premises unless the medications or drugs are labeled according to the requirements of State and Federal law. Packaging of medications must be compatible with the Facility's medication distribution system. All drugs or medications brought into the Facility shall be immediately delivered to the nurses' station. E. Care Of Facility's Property - To preserve the value of the Facility's property for future use, the Resident agrees to use due care to avoid damaging the Facility's property and premises. The Resident shall be responsible for repair or replacement of the Facility's property damaged or destroyed by the Resident. However, the Resident shall not be responsible for such damage as is to be expected from ordinary wear and tear. F. Care Of The Resident's Room - The Facility encourages the Resident to have a home-like environment and will attempt to accommodate all reasonable requests to individualize Resident rooms. For safety reasons, the Facility must concur with any addition or rearrangement of furniture, hanging of pictures, posters, or other similar activities. TX. PROHIBITION AGAINST TRW PAR'T'Y GUARANTOR -FEDERAL AND STATE LAWS PROHIBIT A NURSING HOME FROM REQUIRING A THIRD PARTY GUARANTEE OF PAYMENT TO THE FACILITY AS A CONDITION OF ADMISSION, EXPEDITED ADMISSION OR CONTINUED STAY IN THE FACILITY. HOWEVER, A FACILITY MAY REQUIRE AN INDIVIDUAL WHO HAS LEGAL ACCESS TO THE RESIDENT'S INCOME OR RESOURCES AVAILABLE TO PAY FOR FACILITY CARE TO SIGN A CONTRACT, WITHOUT INCURRING PERSONAL FINANCIAL LIABILITY FOR THE RESIDENT'S COSTS OF CARE, TO. PROVIDE FA('MITY PAYMENT FROM THE RESIDENT'S INCOME OR RESOURCES. 4 kx uate/lime NOV-06-2006(MON) 11;35 717 65197980 NOV-06-2006 11:31 FROM:BEVERLY HEALTH CARE 717 65197980 TO:9095925 P.O10 t P.10/19 X. AGENT AND/OR LEGAL REPRESENTATIVE A. Agent - For the purposes of this Agreement, an Agent is a person who manages, uses or controls funds/assets that may be legally used to pay the Resident's charges or who otherwise acts on behalf of the resident. The Agent's financial obligations are limited to the amount of the funds received or held by the r Agent for the Resident. The Agent assumes no responsibility to pay for the costs of the Resident's care out of the Agent's personal funds. However, as a necessary- party to this Agreement, the Agent is f contractually bound by the terms of this Agreement and may become personally liable for failure to perform duties under the Agreement. If the Agent has control of or access to the Resident's income and/or assets, the Agent agrees to use these Rinds for the Resident's welfare.. The Agent is required to produce financial documentation as proof of the Resident's ability to pay for charges when due and to I make prompt payment for care and services provided to the Resident as specified in the terms of this Agreement. THE AGENT IS REQUIRED TO SIGN THIS AGREEMENT AND AGREES TO DISTRIBUTE TO THE FACILITY, FROM THE RESIDENT'S INCOME OR RESOURCES, PAYMENT WHEN DUE FOR THE ITEMS/SERVICES PROVIDED TO THE RESIDENT. Wherever this Agreement refers to the Resident's financial obligations under this agreement, "Resident" shall be construed to include not only the Resident, but also the obligations of Agent to act on behalf of the Resident. B. Legal Representative - For the purposes of this Agreement, Legal Representative is defined as a person recognized under State law as having the authority to make health care and/or financial decisions for the Resident. The Legal Representative may or may not be court appointed. A Legal Representative may be an attorney-in-fact acting under a Durable Power of Attorney for Health Care, guardian, conservator, next-of-kin, or other person allowed to act for the Resident under State Law. If Legal Representative status has been conferred by a court of law or through appointment by the Resident, copies of documents verifying such status must be provided to the Facility at the time of admission. JAL PAYMENT INFORMATION A. Obligation To Pay Timely - The Facility charges for services provided shall be billed monthly to the Resident. These charges are due and payable by the tenth (10th) day of each month or, in the case of a notice of a rate change, within ten (10) days of mailing of the notice. If payment is pZ received timely, the account balance is considered past due and the Facility may add a late charge to the Resident's account. This late charge shall be assessed on the monthly balance at the lesser of the monthly rate of 1. 5% (one and one-half percent) or the maximum amount permitted by .law. This late charge does not alter any obligations of the Facility or Resident under this Agreement. In addition, under Federal law, failure to pay any amount due the Facility is grounds for discharge of the Resident from the Facility. If a Resident is required to vacate for failure to pay, the Facility shall provide advance notice as set forth under the Transfer and Discharge section of this Agreement. B. Credit Card Charges - The Facility accepts MasterCard and VISA. If the Resident would like the convenience of paying amounts due each month through one of these options, the Resident must provide the needed information and authorization on the Credit Card Authorization form at the back of this Agreement. The Resident recognizes that., unless the Resident has authorized the use of MasterCard or VISA, the Facility does not offer credit or accept installment payments. The Facility's acceptance of a partial payment does not limit the Facility's rights under this Agreement. C. Fee For Returned Checks - A service fee of $25.00 (twenty-five dollars) or the actual fee charged by the bank, whichever is greater, will be charged for any returned check. Rx Date/Time NOV-06-2006(MON) 11:35 717 65197980 NOV-06-2006 11:31 FROM:t3EUERLY HEALTH CARE 717 65197980 TO:9095925 F 011 P-11/19 D. Potential Personal Liability Of Agent -- Agent (includes any Legal Representative serving as the Resident's Agent) shall pay the Facility from the Agent's own resources as liquidated damages an amount equivalent to any payments or funds of the Resident which are available to pay for the Resident's care, which the Agent withholds, misappropriates for personal use, or otherwise does not turn over to Facility for payment of Resident's financial obligations under this Agreement, or an amount equivalent to revenue lost by the Facility due to the Agent's failure to cooperate in the Medical Assistance Program eligibility or re-determination process as required under this Agreement XIL PRIVATE PAY RESIDENTS - A Resident is considered private pay when no State or Federal program is paying for the Resident's room and board. Private Pay Residents may have private insurance or another third party which pays all or some of the Resident's charges. A. Monthly Rate - The Facility's private pay monthly rate is determined in part by the type of room assigned. For this reason, the rate may change if the Resident moves to a different type of room. The Resident agrees to pay the Facility, on or before the day of admission, an amount no less than the first full month's room and board charge at the private pay monthly rate. For each additional month's stay, the Resident agrees to pay the Facility in advance on or before the tenth (10th) day of the month. Any unus _ advance payment shall be refitnded if the Resident becomes covered by the Medical Assistance or Medicare Programs or leaves the Facility before the end of the month. In this case, the Resident shall be refunded a prorated daily room rate based on the total number of days in the calendar month during which the stay occurs. The Resident will be provided with a general list of supplies and services included in the Facility's monthly private pay rate and those supplies and services which are not covered by the monthly private pay rate for which the Resident will be separately charged. A more detailed list of charges for supplies and services not covered by the monthly private pay rate is maintained in the Business Office and is available for review during normal business hours. B. Rate Adjustments - The Facility shall provide advance written notice of any monthly rate adjustment. However, if at any time the Resident's condition requires the Facility to change the room or level of care, the Resident's monthly rate may be changed without prior notice, unless such notice is required by State law. When a notice of a rate adjustment is received, the Resident may choose to end this Agreement. Any rate increase shall be considered as agreed to by all parties when a notice is mailed, unless the Facility is notified to the contrary in writing within ten (10) calendar days of the date of the notice. If the Resident does not agree to the rate increase, the Resident agrees to leave the Facility no later than the day before the rate increase becomes effective. If the Resident fails to leave by this date, the Resident shall be considered to have consented to the increase for the duration of the Resident's stay. C. Primary Responsibility for Payment - Notwithstanding the source of funds for payment for the Facility's charges, the Resident remains primarily responsible for paying all Facility charges, including any charges not covered by a third party payer, unless expressly prohibited by a contractual agreement between the Facility and payer- Non-covered charges may include any coinsurance and/or deductible amounts required by a third party payer. D. Communicating Changes in Assets - It is essential for the Resident to communicate to the Facility any changes in the Resident's assets or resources within ten (10) days of knowledge of the changes in financial status. Upon request by the Facility, the Resident shall provide the required information to the facility within ten days. If the Resident runs out of private monies, it is important to locate alternative payment sources to pay for his or her uninterrupted stay in the Facility. Generally, when private funds are depleted, the Resident applies for Medical Assistance, and application-processing time can be lengthy. The Resident agrees to inform the Facility when the value of his/her remaining assets are within three (3) months of being reduced to an amount that, when combined with the Rx Date/Time . NOV-06-2006(MON) 11;35 717 65197980 P.012 NOV-06-2006 11:32 FROM:BEVERLY HEALTH CARE 717 65197980 70:9095925 P.12/19 Resident's monthly income, is no longer sufficient to pay for the cost of care and services. If the 'Resident's private funds are exhausted during the Resident's stay, and Medicaid payment is available for the Resident, the Facility shall accept Medicaid payments on behalf of the Resident. K Discharge Of Resident - The Facility shall not transfer or evict the Resident solely as a result of the Resident changing his or her manner of payment from Private or Medicare to Medical Assistance, unless the Facility is not certified for Medical Assistance. XIU. MEDICAL ASSISTANCE PROGRAM RESID1EN-f -A Medical Assistance Program Resident is one who receives benefits from the State Medical Assistance Program for a majority of his or her Room & Board charges. The Program may or may not cover charges for additional services/items provided by the Facility, depending on State law. Medicaid eligibility is a requirement for Medical Assistance. A. Applying For Medical Assistance - The Facility makes no guarantee that the Resident's care will be covered by Medicare, Medical Assistance, or any third party insurance or other reimbursement source. The Facility, its agents and associates are hereby released from any liability or responsibility for any claim relating to the failure to obtain such coverage. B. Qualifying For Medical Assistance - The Resident should learn if the Medicaid eligibility requirement is met at the time of admission. If the Resident elects coverage under the Medical Assistance Program, the Resident agrees to act as quickly as possible to establish and maintain eligibility. These actions must include, but are not limited to: (1) timely completion and submission, if applicable, of Resident's application, and (2) taking any and all steps necessary to ensure that the Resident's assets are appropriately spent down and maintained within the allowable limits. The Resident agrees that the Medical Assistance office may release to the Facility any information submitted by the Resident in pursuit of eligibility so that the Facility may assist with and ascertain the status of the application process. C. Providing Application Information And Keeping The Facility Informed - The Resident agrees to provide all of the information necessary for completion of the Medical Assistance Program application and of any subsequent Program eligibility re-determinations in compliance with the Program deadlines. The Resident certifies that any financial information regarding the Resident's income and assets provided is complete and accurate. The Resident agrees to keep the Facility informed of all communication between the Resident and the Medical Assistance agency, no less often than weekly and of the status and progress of the application. The Resident agrees to provide the Facility with copies of any information necessary for the appropriate State agency to process the application and any later eligibility re-determinations. D. Transferring Assets - If the Resident transfers assets, this transfer may disqualify the Resident for Medical Assistance and/or cause a discontinuance of the Resident's Program benefits. The Resident acknowledges that this may result in charge to the Resident for services not paid for by the Program and/or in discharge of the Resident due to non-payment, E. Resident's Share of Cost - The Medical Assistance Program reviews the available monthly income of all Medical Assistance applicants. As a result, most Medical Assistance Residents are required to pay for a reasonable share of the cost of their care, referred to as Share of Cost, Private Portion, Patient Liability, Patient Resource, or similar designation. Payment of that share is the responsibility of the Resident. The State can change the Resident's share of cost at its discretion. Changes in the Resident's Share of Cost must be communicated to the Facility on a timely basis. Rx Date/Time NOV-06-2006(MON) 11;35 717 65197980 P 013 NOV-06-2006 11:32 FROM:BEVERLY HEALTH CARE 717 65197980 T0:9095925 P.13/19 1+. Continuing Payment of Facility Charges Pending Eligibility • When an application for Medical Assistance has been filed, the Resident agrees that while the Resident's application is "pending," the Resident's estimated Share of Cost shall be paid to the Facility on or before the tenth (10th) day of each month. Once the Resident is determined to be eligible for Medical Assistance, the Resident's Share of Cost shall be paid to the Facility on or before the tenth day of each month. If the Resident is retroactively approved for Medical Assistance, previous payments made by the Resident which are covered by Medical Assistance shall be refunded promptly in accordance with the Facility's refund policy which can be reviewed at the Facility's Business Office. Resident and Agent understand that, after the Share of Cost is established by Medical Assistance, failure to pay the Share of Cost may result in the Resident's discharge from the Facility. G. Daily Rate Payment - On admission, the Resident shall be provided with a list of supplies and services generally paid for by the Medical Assistance Program, and those supplies and services not paid for by the Program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility, but not covered by the daily rate, is maintained in the Business Office and is available for review during normal business hours. H. Termination Of Coverage - A Resident who remains in the Facility after Medical Assistance coverage has expired or been retroactively terminated or denied must pay Facility charges as a Private Pay Resident. In this event, the Resident shall be charged based on the private rates, charges and terms in effect at the time of service. 1. Designation Of Facility As Representative Payee - Resident and Agent agree that, in the event the Resident become delinquent in payment of the share of cost obligation, Resident shall arrange for the designation of the Facility as "Representative Payee" of the Resident for any Social Security related benefits or other income sources of the Resident. Payments made from such income sources shall be applied to the Resident's outstanding share of cost amount. In the event that the Agent fails to pay the share of cost from the Resident's funds, the Facility may also notify the appropriate State or Federal agency of this nonpayment. XJV. MEDICARE RESIDENT -A Medicare Resident is one who receives benefits from the Federal Medicare Program for his or her nursing home care. Some additional items and services may be covered by Medicare. A. Medicare Coverage - On admission, the Resident shall be provided with an oral explanation and a written list of supplies and services generally paid by the Medicare program, and those supplies and services not paid for by the Medicare program for which the Resident will be separately charged. A detailed list of charges for supplies and services available in the Facility but not covered under the Medicare program, including the daily coinsurance rate, is maintained in the Business Office and is available for review during normal business hours. R. Limited Coverage - Medicare coverage is established by Federal guidelines and not by the Facility. Medicare coverage is limited in that only a specified level of care is covered for a specified number of days (benefit period). If the Resident no longer meets Medicare coverage criteria, coverage can be ended before the use of all allotted days in the current benefit period. C. Expiration Of Benefits - When Medicare coverage expires, the Resident may remain in the Facility if private pay or other payment arrangements have been made. Tf the Resident wishes to be discharged from the Facility upon expiration of Medicare benefits, he or she must so advise the Facility at the time of the Resident's admission or readmission. If the Resident intends to become private pay when Rx Date/Time NOV-06-2006(MON) 11:35 717 65197980 P.l'1d NOQ-06-2006 11:32 FROM:BEVERLY HEALTH CARE 717 65197980 TO:9095925 P.14/19 kedicare benefits expire, the Resident agrees to pay in advance for one month's room and board at the private pay monthly rate when the Resident changes to private pay status. With the exception of the private portion, if applicable, no advance payment is required from Medicare Residents who convert to Medical Assistance. 1). Coinsurance And Deductibles - The Resident is responsible for payment of any Medicare coinsurance and/or deductibles except as covered by the Medical Assistance Program for dually eligible residents. XV. TRANSFERS AND DISCHARGES A. Notice - The Facility shall give notice to the Resident and, if known, a family member or Legal Representative of the Resident of a transfer or discharge initiated by the facility. Where legally required, this notice shall be given at least thirty (30) days prior to the Resident's transfer or discharge. In cases where the safety or health of the Resident or other individuals in the Facility may be endangered or if other legal reasons exist, notice may be given as soon as practicable before transfer or discharge. The reason(s) for the transfer/discharge shall be provided at the time of notice of transfer/discharge. Notice will also include information regarding the right to appeal a transfer/discharge. B. Reasons for Discharge - The Facility shall only transfer or discharge a Resident under the following conditions. The Resident may be transferred/discharged if it is-necessary for the Resident's welfare and the Resident's needs cannot be met in the Facility. The Resident may also be transferred/discharged because the Resident's health has improved sufficiently so the Resident no longer needs the services provided by the Facility. The Resident may be transferred/discharged because the safety of individuals in the Facility is endangered or because the health of individuals in the Facility would otherwise be endangered. The Resident may be transferred/discharged because the Resident has failed, after reasonable and appropriate notice, to pay for (or to have paid under Medicare or Medical Assistance) a stay at the Facility- The Resident may be transferred/discharged because the Facility ceases to operate. XVL BED-HOLDS - In the event that the Resident is temporarily absent from the Facility for hospitalization or therapeutic leave, the Resident may request that the Facility hold open the Resident's bed during this time. This is known as a "bed-hold." The Resident and a family member or legal representative shall be given written notice of the bed-hold option at the time of the hospitalization or therapeutic leave. A. Medical Assistance Residents - If the Resident's care is paid for under the Medical Assistance Program, the Program may pay for a certain number of bed-hold days. If the Resident's therapeutic leave exceeds the bed-hold period paid for under the Program, the Resident may request an additional bed-hold period from the Facility by agreeing to pay the applicable daily rate. Otherwise, the Resident shall be readmitted upon the first availability of a bed in a non-private room as long as the Resident: 1) requires the services provided by the Facility; and 2) is eligible for Medical Assistance nursing services. B. Private Pay and Medicare Residents- Any Private Pay or Medicare Resident may request a bed-hold from the Facility. A Resident's private insurance may or may not pay for bed-holds. The Medicare program does not reimburse for bed-holds. However, if the Medicare Resident is also Medical Assistance Program eligible, that Program may pay for it certain number of bed-hold days. Othemise, a Private Pay or Medicare Resident requesting a bed-hold must pay- the Facility's prorated private monthly rate during the bed-hold period 9 Rx Oate/Time 717 65197980 NOV-06-2006(MON) 11:35 NOV-06-2006 11:33 FROM:eEVERLY HEALTH CARE 717 65197980 TO:9095925 XVII. RESIDENT'S RIGHTS AND FACILITY POLICY UNDER THE FEDERAL SELF- DETERMINATION ACT N Ulb P. 15/19 A. Right To Make Decisions Regarding Care -The Facility recognizes the right of each Resident to make decisions regarding his or her care. Where a Resident is incompetent, the Facility recognizes the Resident's right to have these decisions made on his/her behalf by a substitute decision maker in accordance with State law. 8. Right To Formulate An Advance Directive- The Facility recognizes the right of each Resident to have an advance directive and will honor advance directives developed in accordance with State law and consistent with the level of care the Facility is licensed to provide. An advance directive is a written document that states choices for health care and/or names someone to make those choices. These choices may include the refusal of certain types of care. A Living Will and a Durable Power of Attorney for Health Care are examples of advance directives. Questions about the Facility's policies regarding health care decision-making and/or advance directives may be presented to the Executive Director. Questions regarding whether to execute an advance directive or about its content should be discussed with the Resident's family, physician and/or attorney. C. An Advance Directive Is Not Required As A Condition Of Admission Or Continued Stay - An advance directive is not necessary in order to be admitted to or to continue to reside in the Facility. However, if the Resident has an advance directive, he or she must make it known to the Executive Director or designee so that it can be reviewed and made a part of the medical record. If the resident is incapacitated at the time of admission, the advance directive information shall be provided to family members or other Resident representatives. However, if the Resident later regains competency, the Facility will provide such information directly to the Resident. XVIII. CHARGES FOR COPIES OF MEDICAL RECORDS -The Facility may charge the Resident for copies of his/her medical record in accordance with either state prescribed rates or the rate commonly charged in the Facility's community. XIX. SOLE AGREEMENT- This Agreement is the only Admission Agreement between the Facility and the parties. Changes to this Agreement are valid only if made in writing and signed by all parties. If changes in State or Federal law make any part of this Agreement invalid, the remaining terms shall stand as a valid Agreement. XX. ASSIGNABILITY - The right of the Resident to reside at the Facility is personal and not assignable. The Resident may not transfer his or her rights under this Agreement to any other person. XXL INTEGRATION - The Parties understand and expressly agree that this Agreement supersedes all other prior discussions, statements, representations, promises, understandings, and agreements between the parties, whether written or oral, and therefore they are of no further force and effect. Because this is a fully integrated agreement, the only discussions, statements, representations, promises, understandings, or agreements that are or will be binding on any of the parties to this Agreement or their employees, affiliates, contractors, agents, or representatives are those expressly set forth in writing in this Agreement, or in other written agreements entered into at the same time as, or subsequent to, this Agreement. 10 Rx Date/T-ime NOV-06-2006(MON) 11:35 NOU-06-2006 11:33 FROM:BEVERLY HEALTH CARE 717 65197980 TO:9095925 RESIDENT RIGHTS UNDER FEDERAL LAW This document is a summary of certain provisions of Federal law and regulations, and is expressly not included as a part of the Agreement(s) between the Resident and Facility. These rights are conferred by Federal laws and regulations and are not conferred by the contract between the parties. P. 016 P. 16/19 The Resident has a right to a written description of the facility's policies to implement advance directives and applicable State law as well as written information concerning the right to accept or refuse medical or surgical treatment and, at the individual's option, formulate an advance directive 2. The Resident has a right to a dignified existence, self-determination, and to communication with and access to persons and services inside and outside the Facility. The Facility must protect and promote the rights of each resident. The Resident has a right to exercise his or her rights as a Resident of the Facility and as a citizen or resident of the United States. In the case of a resident adjudged incompetent under the laws of a State by a court of competent jurisdiction, the rights of the resident are exercised by the person appointed under State law to act on the resident's behalf. In the case of a resident who has not been adjudged incompetent by the State court, any legal surrogate designated in accordance with State law may exercise the resident's rights to the extent provided by State law. 4. The Resident has the right to be free of interference, coercion, discrimination, or reprisal from the Facility in exercising his or her rights. 5. The Resident has a right to be informed both orally and in writing and in a language that the Resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. 6. The Resident has the right to be fully informed, in a language he or she can understand, of his or her total health status, including but not limited to his or her medical condition. 7. The Resident has the right to refuse treatment, to refuse to participate in experimental research and to formulate an advance directive. 8. The Resident has the right to exercise his or her right to file a grievance with the State survey and certification agency concerning Resident abuse, neglect, and misappropriation of Resident property in the Facility. 9. The Resident has the right to manage his or her financial affairs. 10. The Resident has a right to choose an attending physician and to information about the name, specialty and way of contacting the physician responsible for the Resident's care. 717 65197930 1 1. The Resident has a right to oral and written information about how to apply for and use Medicare and Medical Assistance benefits, and how to receive refunds for previous payments covered by such benefits. Rx Date/Time NOV-06-2006(MON) 11;35 NOU-06-2006 11:33 FROM:BEUERLY HEALTH CARE 717 65197980 717 65197980 TO:9095925 12. The Resident has a right to be fully informed in advance about care and treatment and any changes in that care or treatment that may affect the Resident's well-being. P 017 P. 17z19 13. The Resident has a right to participate in planning his or her care and treatment or changes in care and treatment unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State. 14. The Resident has the right to personal privacy and confidentiality of his or her personal and clinical records. 15. The Resident or Legal Representative has the right, upon oral or written request, to access all records pertaining to himself or herself, including current clinical records, within twenty-four hours, excluding weekends and holidays. After receipt of his or her records, the Resident Or Legal Representative has the right to purchase (at a cost not to exceed the community standard) photocopies of the records or any portions of them upon request and two working days advance notice to the Facility. 16. Each resident entitled to Medical Assistance benefits has a right to be informed, in writing, at the time of admission or when becoming eligible for Medical Assistance, of (A) the items and services that are included in the facility's reimbursement under the State plan and for which the resident may not be charged; (B) those other items and services that the facility others and for which the resident may be charged, and the amount of charges for those services; and (C) to be informed when changes are made to the items and services specified under this section. 17. The resident has a right to be informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare or by the facility's per diem rate. 18. The resident has a right to receive a written description of 1) the manner that the facility will protect personal funds 2) description of the requirements and procedures for establishing eligibility for Medical Assistance, including the right to request an assessment under Section 1924 (c) of the Social Security Act which determines the extent of a couple's non-exempt resources at the time of institutionalization and attributes to the community spouse an equitable share of resources which cannot be considered available for payment toward the cost of the institutionalized spouse's medical care in his or her process of spending down to Medical Assistance eligibility levels 3) the right to file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility. 19. The Resident may approve or refuse the release of personal and clinical records to any individual outside the Facility except when: a. The Resident is transferred to another health care institution. b. Record release is required by law or a third party payment contract. c. The Facility has a legal right to release such records without Resident approval. 20. The Resident has a right to voice grievances with respect to treatment or care that fails to be furnished, without discrimination or reprisal for voicing grievances. F- 1 Rx Date/Time NOV-06-2006(MON) 11:35 NOU-06-2006 11:33 FROM:BEUERLY HEALTH CARE 717 65197980 717 65197980 TO:9095925 21 The Resident has a right to prompt efforts by the Facility to resolve grievaric e,, I it. those with respect to the behavior of other Residents. 22. The Resident has a right to examine the results of the most recent survey of Ili( J conducted by Federal or State surveyors and any plan of correction in of ec.-i will, i ; the Facility. 23. The Resident has a right to receive information from agencies acting as client adr be afforded the opportunity to contact the agencies. 24 The Resident has a right to refuse to perform services for the Facility. P 018 P. 18/19 25, The Resident has a right to agree to perform voluntary or paid services tot tht!i l p?irt$t; F' she desires, if there is no medical reason which would contradict the performiitir of tlr:. services, and if compensation for paid services is at or above prevailing rates 26. The Resident has the right to privacy in written communications, including the riehl lc? and receive mail promptly that is unopened. The Resident has a right of access, to postage and writing implements at the Resident's own expense. 27. The Resident has the right to immediate access to any of the following. a. Any representative of the Secretary of the U. S. Department of Health and lk is l;; a, Services. b. Any representative of the State. c. The Resident's individual physician. d. The State's long-term care ombudsman, e. The agency responsible for the protection of and advocacy system far nicoitall developmentally disabled individuals. f. Subject to the Resident's right to deny or withdraw consent at any time, itttn? ??ep family or other relatives of the Resident or others who are. visitint., with th; of the Resident. 28. The Facility must provide reasonable access to any Resident by an entity or individual lh , provides health, social, legal, or other services to the Resident, subject to thr Rericlcill'a rirh? to deny or withdraw consent at any time. 29. The Resident has a right to have reasonable access to the private use of a t.elephont 30. The Resident has a right to retain and use personal possessions, includin !. sornc fumi0ltttttm. and appropriate clothing, as space permits, unless to do so would infringe art the flpht,, or health and safety of other Residents. 31. The Resident has a right to share a room with his or her spouse when married Itef?idt'nt It%-c if, the same facility and both spouses consent to the arrangement. 32. Each Residett has a right to self-administer drug: unlts the l=at.ility inter(liScil)llutn ti t0„nl1,fi: determined for a particular Resident that ihi% pracove i% unsafe- F1 Rx Date/Time NOV-06-2006(MON) 11:35 717 65197980 P 919 NOV-06-2006 11:33 FROM:BEVERLY HEALTH CARE 717 65197980 TO:9095925 P.19/19 A 33, The Resident has a right to be free from any physical restraints imposed or psychoactive drugs administered for the purposes of discipline or convenience, and not required to treat the Resident's medical symptoms. 34. The Resident has the right to be free from verbal, sexual, physical, or mental abuse, corporal punishment and involuntary seclusion. 35_ The Resident has a right to choose activities, schedules and health care consistent with his or her interests, assessments, and plans of care. 36. The Resident has a right to receive advance notice of transfers or discharges of the Resident as required by law. The Resident has a right to receive notice before the Resident's room or roommate is changed. 37. The Resident has a right to organize and participate in Resident groups in the Facility, and the Resident's family has the right to meet with families of other Residents. 38_ The Resident has a right to participate in social, religious, and community activities that do not interfere with the rights of the Residents. 39. The Resident has a right to reasonable accommodation of individual needs and preferences except where the health or safety of the Resident or other Residents would be endangered. 40. The Resident has a right to freedom of choice of providers in accordance with applicable law and subject to the provider's compliance with all applicable laws and reasonable rules and regulations of the Facility. RESIDENT-SPECIFIC INFORMATION X Payer SourceediT his Facility acce/ed ollowing types of payments [ Private [ car e [ Assis tance eterans Administration XXIII ACKNOWLEDGEMENTS - By signing the Admission Agreement Signature Page, the Resident/Agent/Legal Representative acknowledges that he or she has been given and has read this Agreement in its entirety, and all addenda. The Resident also acknowledges that the following information was provided upon or before admission by the Facility. Initial the lines below (if not applicable, write N/A): 1. A list of supplies and services that are included in the Facility's private monthly rate or that will be paid for by the Medical Assistance or Medicare programs and a list of supplies and services not included in the Facility's private monthly rate or paid for by the Medical Assistance or Medicare programs for which the Resident will be separately charged 5 2. Information about the Facility's bed-hold procedures. 1_$' 3. A written explanation of how to apply for and use Medicare and Medical Assistance benefits and how to receive funds for previous payments covered by these benefits. 54. A statement explaining that the Resident may file a grievance with the appropriate State Agency about resident abuse, neglect, and/or misuse/theft of resident personal property in the Facility. -5. Copies of the State Resident Rights. 6. A written explanation of the Facility's Rules and Regulations. 7. Where applicable, if your condition warrants, you may be placed in the Facility's Medicare-,Certified Distinct Part Unit. At some point, circumstances may occur which will make residt ' another unit more appropriate for you. In that case, the Facility will discuss such a trans ith you. Under law, you cannot be discharged from this Facility unless s, flowing an appeal, it is determined that you may be you agree or 7 involuntarily discharged or tran rred. 4 S 8. I do do not shave an advance directive. 5 9. I have been informed, both orally and in writing, in a language I understand, of my rights and the rules and regulations governing my conduct and responsibilities during my stay at the Facility. d;5 10. I have been given a copy and had an opportunity to review the Facility's Notice of Privacy Practices. XXIV. NOTICES - Notices shall be mailed to the address (es) indicated below. The Agent and/or Legal Representative are responsible for notifying the Facility in writing of any change of address. The Resident designates the following person(s) to be notified when any legally required notices are provided to the Resident, Agent, and/or Legal Representative. Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident U G. CD z CD z c 11 A. Legal Representative And/Or Agent Name 9444bO•t7 C=6T3- .. ` ,P ; - "Home Phone [ ][ ][ ]( ]( ][ ][ ][ ][ ][ ] Work Phone[ [ ][ ][ ]( ]( ][ ][ ][ ] r 1 IJI 013A 10? 7- Street City State B. Other Person To Be Notified 1 --Name °r°? coq,, er Home Phone [-7][ 1] [7 [)-1[21P1[01[71 [2] (o] Work Phone[ ][ ][ ][ ][ ][ ][ ] ] fnf rep e-, 5 V V - Street City State D Zip `7 //d Zip XXV. MAIL - The Facility is authorized to handle the Resident's mail as follows: (Check one box only.) [ ] All mail given directly to the Resident [ ] Forward all of the Resident's mail to XXVI. RESIDENT'S PHYSICIAN A. NAME: B. SPECIALTY- C. ADDRESS: D. TELEPHONE: - 11/11 [ ] All mail read to the Resident XGive personal mail to the Resident; forward business mail to: XXVH. RESIDENT TRUST FUND AUTHORIZATION - A Resident Trust Fund is an amount of money held by the Facility for the Resident's personal use. (Examples of use: To allow the resident to pay for room and board, beauty shop charges, cigarettes, postage stamps, or other similar expenses as desired by the Resident.) By signing below, the Resident authorizes the Facility to set up a trust fund in his/her name. The individual financial records shall be available through quarterly statements, and on request, to the Resident or his/her Agent or Legal Representative. The Resident understands that all withdrawals Rev. 03/13/03 zrVhite - Business Office Pink - Medical Records Yellow - Resident J Q+ CD z 0 12 shall be authorized by the Resident or his/her Agent or Legal Representative in writing. The following persons may authorize withdrawals on the Resident's behalf: Name of Authori'ze4 Person Resident's Signature Witness if Resident Signed with a Mark Legal Representative's Signature (if applicable) Agent's Signature (if applicable) Name of Authorized Person Date ..Date Date Date XXVIIL CREDIT CARD AUTHORIZATION - Facility accepts MasterCard and VISA. If Resident wo like the convenience of paying amounts due each month through one of these, please provide the needed ' ormation and authorization: Credit Card Expiration Date Account # I hereby authorize Facility to c e the account listed above for monthly charges incurred under this Agreement: or Agent's Signature Date If the Resident is unable to consent or sign this provision 6?use of physical disability or mental incompetence or is a minor and this provision is being signed by-an authorized representative, complete the following: Dater Relationship to Resident: Signature: Authorized Representative Witness: For Facility: . Rev. 03/13/03 W-hite - Business Office Pink - Medical Records 13 Date: Yellow - Resident ro a: z z 0 Authorized Representative Signature: Print Name and Title: 70 z ?A Z C Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident 14 ADMISSION AGREEMENT SIGNATURE PAGE XXIX. PARTIES - The parties to this Agreement are: 'Glaa?il ?On(Name ofFacty) ? DDiyZ?? (Name of Resident) (Name of Resid nt's Agent) (Name of Resident's Legal Representative) If the Legal Representative signs the Agreement, check the Type of Legal Representative (below): [ ] Conservator of Person [ ] Guardian [ ] Durable Power of Attorney [ J Agent Acting [ J Conservator of Estate for Health Care (DPAHC) Under General [ ] Other, specify POA If you are signing this Agreement on behalf of the Resident, note your relationship to the Resident: My relationship to the Resident is 4- ?&[rrE1L On this ?t day of _.e 10 ,20A4 the above Parties agree to be bound by the provisions of this Agreement and agree that on the day of - 209, the Resident shall be admitted to this Facility. Resident Date _ Address... Resident's Social Security Number City, State, Zip Resident's Telephone Number Witness if Resident Signed with a Mark Date Witness If Resident Signed with a Mark Date Legal Representative Date Legal Representative's Address Legal Representative's Social Security No. Legal Representative's Telephone Number Rev. 03;13/03 x c? z z 0 White - Business Office Pink - Medical Records Yellow - Resident 15 r ? ? }3 -4-77/- Agent Ags ress Facility Executive Director or Designee Facilit N PE 7? p <Ar ?t vac Facility Address 2-16-04 ai-e Age r ' m er ? Date s Note: The signatures above refer to the information contained on pages 1 through 16 of the Admission Agreement. II 1 c Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident 16 I i RESIDENT AND FACILITY ARBITRATION AGREEMENT' (NOT A CONDITION OF ADMISSION - READ CAREFULLY) f This Arbitration Agreement is executed by ?LAW, K and (the "Faci ity' ("Resident" or "Resident's Authorized Represent, rve",k hereafter collectively referred to as "Resident") in conjunction with an agreement for admission and ford the provision of nursing facility services (the "Admission Agreement") by Facility to Resident. The parties to this Arbitration Agreement acknowledge and agree that upon execution, this Arbitration J Agreement becomes part of the Admission Agreement, and that the Admission Agreement evidences a transaction involving interstate commerce governed by the Federal Arbitration Act. It is understood and agreed by Facility and Resident that any and all claims, disputes, and controversies (hereafter collectively referred to as a "claim" or collectively as "claims") arising out of, or in connection with, or relating to any way to the Admission Agreement or any service or health care provided by the Facility to the Resident shall be resolved exclusively by binding arbitration to be conducted at a place agreed upon by the Parties, or in the absence of such an agreement, at the Facility, in accordance with the National Arbitration Forum Code of Procedure, which is hereby incorporated into this Agreement\1' and not by a lawsuit or resort to court process. This agreement shall be governed by and interpreted under the Federal Arbitration Act, 9 U.S.C. Sections 1-16. This agreement to arbitrate includes, but is not limited to, any claim for payment, nonpayment, or refund for services rendered to the Resident by the Facility, violations of any right granted to the Resident by law or by the Admission Agreement, breach of contract, fraud or misrepresentation, negligence, gross negligence, malpractice, or claims based on any departure from accepted medical or health care or safety standards, as well as any and all claims for equitable relief or claims based on contract, tort, statute, warranty, or any alleged breach, default, negligence, wantonness, fraud, misrepresentation, suppression of fact, or inducement. However, this agreement shall not limit the Resident's right to file a grievance or complaint with the Facility or any appropriate government agency from requesting an inspection from such an agency, or from seeking review under 42 C.F.R. section 431.200 et seq. of a decision to transfer or discharge the Resident. The parties agree that damages awarded, if any, in an arbitration conducted pursuant to this Arbitration Agreement shall be determined in accordance with the provisions of the state or federal law applicable to a comparable civil action, including any prerequisites to, credit against, or limitations on, such damages. Any award of the arbitrator(s) may be entered as a judgment in any court having jurisdiction. In the event a court having jurisdiction finds any portion of this agreement unenforceable, that portion shall not be effective and the remainder of the agreement shall remain effective. It is the intention of the parties to this Arbitration Agreement that it shall inure to the benefit of and bird the parties, their successors, and assigns, including without limitation the agents, employees and servants of the Facility, and all persons whose claim is derived through or on behalf of the Resident, including any parent, spouse, sibling, child, guardian, executor, legal representative, administrator, or heir of the Resident. The parties further intend that this agreement is to survive the lives or existence of the parties hereto. 11 Information about the National Arbitration Forum, including a complete copy of the Code of Procedure, can be o! lain c;d in the Forum at 500-474-2371, by fax at 651-604-6778 or toll-free fax ut 566-743-4517, nr on the interret at httl:, ;'.a; , ; b_ forum. com. Rev. 05/13/03 White - Business Office Pink - Nledical Records Yellow - Resident i I i t +1 4. All claims based in whole or part on the same incident, transaction, or related course of care or services provided by the Facility to the Resident shall be arbitrated in one proceeding. A claim shall be waived and forever barred if it arose and should reasonably have been discovered prior to the date upon which notice of arbitration is given to the Facility or received by the Resident and such claim is not presented in the arbitration proceeding, THE PARTIES UNDERSTAND AND AGREE THAT THIS CONTRACT CONTAINS A BINDING ARBITRATION PROVISION WHICH MAY BE ENFORCED BY THE PARTIES, AND THAT BY ENTERING INTO THIS ARBITRATION AGREEMENT, THE PARTIES ARE GIVING UP AND WAIVING THEIR CONSTITUTIONAL RIGHT TO HAVE ANY CLAIM DECIDED IN A COURT OF LAW BEFORE A JUDGE AND A JURY, AS WELL AS ANY APPEAL FROM A DECISION OR AWARD OF DAMAGES. The Resident understands that (I) he/she has the right to seek legal counsel concerning this Arbitration Agreement, (2) that execution of this Arbitration Agreement is not a precondition to admission or to the furnishing of services to the Resident by the Facility, and (3) this Arbitration Agreement may be rescinded by written notice to the Facility from the Resident within thirty days of signature. If not rescinded within thirty days, this Arbitration Agreement shall remain in effect for all subsequent stays at the Facility, even if the Resident is discharged from and readmitted to the Facility. The undersigned certifies that he/she has read this Arbitration Agreement and that it has been fully explained to him/her, that he/she understands its contents, and has received a copy of the provision and that he/she is the Resident, or a person duly authorized by the Resident or otherwise to execute this agreement and accept its terms. Date: ignature: (Resident) Witness: If the resident is unable to consent or sign this provision because of physical disability or mental incompetence or is a minor and an authorized representative is signing this provision, complete the following: Date: Relationship to Resident: Signature: (Authorized representative) Witness: For Facility- Rev. 05/13/03 White - Business Office Pink - Medical Records Yellow - Resident z z c I or U Date: 0?/(,A Authorized Representative S Print Name and Title: 10W-$;4? Rev. 03/13/03 White - Business Office Pink - Medical Records Yellow - Resident f as • EXHIBIT "B" C? r1.Fr . ND c o MEDICAID '99 NOT ELIGIBLE WESTMINSTER DRIVE CARLISLE PA 17013-0599 NOTICE CAO RETURN ADDRESS CSLD 0000 *01020984000* GETRUDE FREEMAN WEST SHORT HEALTH & REHAB 770 POPLAR CHURCH ROAD CAMP HILL PA 17011 Notice ID: 6,,713140 Co RECORD DIST CAT GG PS 21 0109840 0 LTC 00 WORKER: W PALM TELEPHONE: (717) 240-2700 DATE: 07/13/2006 NOT. 042 OPT: D TYPE: N IF YOU DO NOT UNDERSTAND OUR DECISION OR NAVE ANY QUESTIONS, PLEASE CONTACT YOUR Rl7RKER INNEDIATELY. You have been determined not eligible for benefits based on your application dated 05/31/2006. As a condition of eligibility for Medicaid and Long-Term Care benefits, you were asked to provide verification of certain information. You failed to provide the verification for the following person(s) and item(s) by this date 07/12/06 Items: Name: INCOME - GERTRUDE FREEMAN RESOURCES MA51 OPTIONS LETTER Citation: 55 Pa. Code 201.1, 201.3 PAGE 1 OF 1 If you disagree with our decision, you have the right to appeal. See attached form for a complete expalnation of Your right to appeal and to a fair hearing. If you are currently receiving benefits and your oral request for a hearing is received in the County Assistance Office or your written request is postmarked or received on or before 07/26/2006 your assistance still continue pending the hearing decision, except when the change is due to State or Federal law. GETRUDE FREEMAN WEST SHORT HEALTH & REH'XB 770 POPLAR. CHURCH ROAD CAMP HILL PA 17011 aoa CUMBERLAND CAO P.O. BOX 599 33 WESTMINSTER DRIVE CARLISLE PA 17013-0599 MIDPENN LEGAL SERVICES 401-405 LOUTHER STREET CARLISLE PA 17013 Notice ID: 68713140 CO. RECORD DIST, . CAT GG PS 21 0109840 0 LTC 00 WORKER: W PALM APPEAL: 07/26/2006 TELEPHONE: (717) 240-2700 DATE: 07/13/2006 NOT: 042 OPT: D TYPE N - -_ -.- - •,-"" ` 1" I I IC or?i,n Ur l riles t-UHM -AND "RETURN 0THE" T PORTION TO CAO. J r_ - VI 1 V ?1 W IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 06-6967 Civil Term Beverly Enterprises, Inc., D/B/A West Shore Health and Rehabilitation Center vs Dorothy Scott Commonwealth of Pennsylvania County of Dauphin SS. AFFIDAVIT OF SERVICE I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 10:54 AM on 12/09/2006, I served Dorothy Scott at 242 Woodbine Street , Harrisburg, PA 17110 in the manner described below: ® Defendant(s) personally served. ? Adult family member with whom said Defendant(s) reside(s). Relationship is ? Adult in charge of Defendant(s) residence who refused to give name and/or relationship. ? Manager/Clerk of place of lodging in which Defendant(s) reside(s). ? Agent or person in charge of Defendant's office or usual place of business. ? an officer of said Defendant's company. ? Other: a true and correct copy of Notice to Defend, Complaint, Verification issued in the above captioned matter. Description: Sex: Female - Age: 50 - Skin: Black - Hair: Gray - Height: 510811 Weight: 140 to and subscribed before me on this _ day of L>cc- , 20b(e. NOTARIAL SEAL EBONE M. TURNER, Notary Public City of Harrisburg, Dauphin County Commission Ex i e April a 200 S14nkowsky Investi 3 6 Fawn Ridge Nor Harrisburg, PA 17 (800) 276-0202 Atty File#: 06-6967 - Our File# 297 Law Firm: c u jer Address: 305 North Front Street, Suite 401, Harrisburg, PA, 17101 Telephone: (717) 909-5925 ORIGINAL ? l IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/ B/ A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. No. 06-6967 Civil Term DOROTHY SCOTT, Defendant. : CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Beverly Enterprises, Inc. d/b/a West Shore Health and Rehabilitation Center ("Petitioner"), by and through its attorneys, SCHUTJER BOGAR LLC, and pursuant to the provisions of Pa. R.C.P. No. 1531, makes the following petition for a preliminary injunction and, in support thereof, avers: 1. On or about December 5, 2006, Petitioner filed its Complaint against Dorothy Scott ("Respondent") 2. The Complaint sets forth two claims against Respondent relating to her breach of the Admission Agreement ("Agreement") she signed as representative for her mother, Gertrude Freeman ("Ms. Freeman"), and the breach of her statutory duty to support her mother pursuant to 23 Pa. C.S. § 4603(a) by failing to assist with securing financial support through the Medicaid system for her mother and failing to cooperate in the appeal of the denial of Ms. Freeman's Medical Assistance application by providing the necessary financial documentation to the Cumberland County Assistance Office to determine her mother's eligibility for benefits. See Complaint, Exhibit "A." ORIGINAL 3. The very nature of the breaches of the Agreement and of Respondent's statutory duty of support, a duty which encompasses the duty to not actively work against Medicaid approval by failing to assist and cooperate in qualifying for Medical Assistance benefits through a refusal to provide the documentation necessary to establish the eligibility of Ms. Freeman for benefits, presents an issue of immediate and irreparable harm to Petitioner, as Ms. Freeman's application for Medical Assistance benefits was denied due to the lack of necessary documentary evidence to establish her eligibility for Medical Assistance benefits. 4. While an appeal is currently pending of that denial, if Respondent does not provide the documents and information requested by the Cumberland County Assistance Office prior to or a the time of a hearing on that appeal, the appeal will be finally denied and any further appeal to the Commonwealth Court would be without merit. 5. The requested injunction would restore the parties to the status quo as it existed immediately prior to the breach of Respondent's statutory duty to support her mother and prior to the breach of the Agreement, as she has a statutory duty to support her mother that includes the duty to assist with securing financial support through the Medicaid system and the duty to not actively work against Medicaid approval and she has a contractual duty to cooperate with the Medical Assistance application process. 6. Greater injury would result from the denial of the requested injunction than from the granting of the same, as absent the injunction, without the documentation necessary to establish the eligibility of Ms. Freeman for Medical Assistance benefits, the appeal of the denial of the application for Medical Assistance benefits will ultimately be denied. 7. Petitioner's right to relief is clear. See Complaint, Exhibit "A." 8. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Respondent and Ms. Freeman have been financially unable to fully compensate Petitioner for the care and services that it has rendered and continues to render to Ms. Freeman. 9. A bond in the amount of $100.00 should be adequate in the event that it is later determined that the issuance of the instant petition was in error. WHEREFORE, Petitioner respectfully requests that this Court schedule an immediate hearing on its request for injunctive relief, and thereafter issue a Decree ordering specific performance of the Agreement between the parties and of the statutory duty of Respondent to support her mother. Dated 0 Respectfully submitted, SCHUTJER BOGAR LLC By: Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 305 North Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Petitioner IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/ B/ A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. No. 06-6967 Civil Term DOROTHY SCOTT, Defendant. : CIVIL ACTION - EQUITY ORDER AND NOW, this ?.?1l? day of _J )7%? a.1 :!)-= 2002 a hearing in the above-captioned matter on the petition for the issuance of a preliminary injunction is scheduled for A144 / a 2OU6-at J,,Od ?.m. in Court Room No. Cumberland County Courthouse, One Courthouse Square, Carlisle, Pennsylvania 17013. BY THE COURT: .c n e\ ORIGINAL VINb AIMNNU h E :Z Wd E- NVr Loot 'U 01 IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/ B/ A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. DOROTHY SCOTT, Defendant. No. 06-6967 Civil Term CIVIL ACTION - EQUITY PRAECIPE TO WITHDRAW WITHOUT PREJUDICE PETITION FOR PRELIMINARY INJUNCTION AND BRIEF IN SUPPORT OF PETITION FOR PRELIMINARY INJUNCTION TO THE PROTHONOTARY: Kindly withdraw, without prejudice, the Petition for Preliminary Injunction and Brief in Support of Petition for Preliminary Injunction that was filed in the above- captioned matter on December 26, 2006. Respectfully submitted, SCHUTJER BOGAR LLC Dated 5 ° 0 By: 1304 - Bradley A. Schutjer Attorney I.D. 75954 (717) 909-5921 Maria Macus-Bryan Attorney I.D. 90947 (717) 909-8640 305 N. Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff ORIGINAL CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Withdraw Without Prejudice Petition for Preliminary Injunction and Brief in Support of Petition for Preliminary Injunction was served first-class, United States mail, postage prepaid, upon the following: Dorothy Scott 242 Woodbine Street Harrisburg, PA 17110 Dated. ZV'r1q B v?/ • Y• Maria G. Macus-Bryan t C--Mk C? 5 1 - - f I - f7 A IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA : CIVIL ACTION - LAW : NO. 06-6967 CIVIL TERM IN RE: PETITION FOR PRELIMINARY INJUNCTION ORDER OF COURT AND NOW, this 8`" day of February, 2007, upon consideration of the attached BEVERLY ENTERPRISES, INC., DB/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff V. DOROTHY SCOTT, Defendant letter from Maria G. Macus-Bryan, Esq., Attorney for Plaintiff, the hearing in the above matter previously scheduled for February 12, 2007, is cancelled. BY THE COURT, Bradley A. Schutjer, Esq. Maria Macus-Bryan, Esq. 305 N. Front Street Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff Dorothy Scott 242 Woodbine Street Harrisburg, PA 17110 Defendant, pro Se ?- og o 7 L?- :rc t w-iX? { I .5CHUTJER I BOGAR LAC attorneys & consultants Email: mmacus-bryan@schutjerbogar.com Direct Dial: (717) 909-8640 February 5, 2007 Curt Long, Prothonotary Cumberland County Courthouse One Courthouse Square Carlisle, PA 17013 Re: Beverly Enterprises, Inc. d/b/a West Shore Health and Rehabilitation Center v. Dorothy Scott; Docket No.: 06-6967 Civil Term Dear Mr. Long: Enclosed for filing, please find an original and two (2) copies of a Preacipe to Withdraw Without Prejudice Petition for Preliminary Injunction and Brief in Support of Petition for Preliminary Injunction in the above-captioned matter. Kindly time-stamp the enclosed extra copies and return same in the self- addressed, stamped envelope that we provided. Additionally, a hearing has been scheduled for February 12, 2007 before Judge Oler on the aforementioned Petition for Preliminary Injunction and Brief in Support of Petition for Preliminary Injunction. Kindly inform Court Administration of the withdrawal of the Petition so that the aforementioned hearing will be canceled. If you should have any questions, please do not hesitate to contact me at the number above. Thank you for your attention and assistance in this matter. Sincerely,. Maria G. Macus-Bryan Enclosures cc: The Honorable J. Wesley Oler Jr. (via regular mail) Taryn N. Dixon, Court Administration (via regular mail) Cynthia McCarthy (via electronic correspondence) Dorothy Scott (via regular mail) 305 N. Front Street, Suite 401, Harrisburg, PA 17101 - Fax (717) 909-5925 • www.schut erbogar.com IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/B/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. ; No. 06-6967 Civil Term DOROTHY SCOTT, Defendant. CIVIL ACTION - EQUITY PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Beverly Enterprises, Inc. d/b/a West Shore Health and Rehabilitation Center ("Petitioner"), by and through its attorneys, SCHUrJER BOGAR LLC, and pursuant to the provisions of Pa. R.C.P. No. 1531, makes the following petition for a preliminary injunction and, in support thereof, avers: 1. On or about December 5, 2006, Petitioner filed its Complaint against Dorothy Scott ("Respondent"). 2. The Complaint sets forth two claims against Respondent relating to her breach of the Admission Agreement ("Agreement") she signed as representative for her mother, Gertrude Freeman ("Ms. Freeman"), and the breach of her statutory duty to support her mother pursuant to 23 Pa. C.S. § 4603(a) by failing to assist with securing financial support through the Medicaid system for her mother and failing to cooperate in the appeal of the denial of Ms. Freeman's Medical Assistance application by providing the necessary financial documentation to the Cumberland County Assistance Office to determine her mother's eligibility for benefits. See Complaint filed with the Cumberland County Prothonotary on December 5, 2006. ORIGINAL I_ . 3. The very nature of the breaches of the Agreement and of Respondent's statutory duty of support, a duty which encompasses the duty to not actively work against Medicaid approval by failing to assist and cooperate in qualifying for Medical Assistance benefits through a refusal to provide the documentation necessary to establish the eligibility of Ms. Freeman for benefits, presents an issue of immediate and irreparable harm to Petitioner, as Ms. Freeman's application for Medical Assistance benefits was denied due to the lack of necessary documentary evidence to establish her eligibility for Medical Assistance benefits. 4. While an appeal is currently pending of that denial, if Respondent does not provide the documents and information requested by the Cumberland County Assistance Office prior to or a the time of a hearing on that appeal, the appeal will be finally denied and any further appeal to the Commonwealth Court would be without merit. 5. The requested injunction would restore the parties to the status quo as it existed immediately prior to the breach of Respondent's statutory duty to support her mother and prior to the breach of the Agreement, as she has a statutory duty to support her mother that includes the duty to assist with securing financial support through the Medicaid system and the duty to not actively work against Medicaid approval and she has a contractual duty to cooperate with the Medical Assistance application process. 6. Greater injury would result from the denial of the requested injunction than from the granting of the same, as absent the injunction, without the documentation necessary to establish the eligibility of Ms. Freeman for Medical Assistance benefits, the . .k appeal of the denial of the application for Medical Assistance benefits will ultimately be denied. 7. Petitioner's right to relief is clear. See Complaint. 8. Petitioner lacks an adequate remedy at law, as upon information and belief, at all times material hereto, Respondent and Ms. Freeman have been financially unable to fully compensate Petitioner for the care and services that it has rendered and continues to render to Ms. Freeman. 9. A bond in the amount of $100.00 should be adequate in the event that it is later determined that the issuance of the instant petition was in error. WHEREFORE, Petitioner respectfully requests that this Court schedule an immediate hearing on its request for injunctive relief, and thereafter issue a Decree ordering specific performance of the Agreement between the parties and of the statutory duty of Respondent to support her mother. Respectfully submitted, Dated;a 10 ZDD4 SCHUT)ER BOGAR LLC Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 305 North Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Petitioner 3 . 1 11 qh? CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petitioner's Petition for Preliminary Injunction was served first-class, United States mail, postage prepaid, upon the following: Dorothy Scott 242 Woodbine Street Harrisburg, PA 17110 Dated: 3 n-7 By: 6q,?A-MAA,, &W"O Catherine Klobucar, Paralegal C ? -r1 ? r :x = FiM _a n.J .w7 -C IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D / B / A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. DOROTHY SCOTT, Defendant. No. 06-6967 Civil Term : CIVIL ACTION - EQUITY AMENDMENT TO PETITION FOR PRELIMINARY INJUNCTION AND NOW, COMES, Beverly Enterprises, Inc. d/b/a West Shore Health and Rehabilitation Center ("Petitioner"), by and through its attorneys, SCHUTJER BOGAR LLC, and pursuant to the provisions of Pa. R.C.P. No. 1531, makes the following amendment to it petition for a preliminary injunction and, in support thereof, avers: 1. In accordance with Cumberland County Local Rule 208.3(a)(2), on February 8, 2007, in response to Petitioner's request that the February 12, 2007 hearing be withdrawn without prejudice, The Honorable J. Wesley Oler, Jr., issued an Order of Court canceling the aforementioned hearing. 2. In accordance with Cumberland County Local Rule 208.3(a)(9), Petitioner is unaware of whether Respondent has retained counsel of record, and to date, Petitioner has not received a Entry/Notice of Appearance of counsel of record for Respondent. ORIGINAL Respectfully submitted, Dated: 0-W7 SCHUIJER BOGAR LLC By Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 305 North Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Petitioner J 1 CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Petitioner's Amendment to Petition for Preliminary Injunction was served first-class, United States mail, postage prepaid, upon the following: Dorothy Scott 242 Woodbine Street Harrisburg, PA 17110 Dated: lo 7 By: 61th am, L??'nM2 Catherine Klobucar, Paralegal IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/B/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff,' V. No. 06-6967 Civil Term DOROTHY SCOTT, Defendant. CIVIL ACTION - EQUITY ORDER AND NOW, this day of , 200 1 7- in the above-captioned matter on the petition for the issuance of a injunction is scheduled for _Md-1)JAq A-4I -7, 2007, at ,71 in Court Room No. , Cumberland County Courth Courthouse Square, Carlisle, Pennsylvania 17013. OAR $e zoos S/ r , a hearing Q?.m. One BY THE COURT: .? r-- . ? ,-- ry ?. ? ?-- ?»-? ?, ..f. ?f?. ? ?'' ":? ? L? i yt? ???? ?"? ??^'? ?? ? ? z ?? A r IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/B/A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. No. 06-6967 Civil Term DOROTHY SCOTT, Defendant. CIVIL ACTION - And now, the -- E--- day of 2007, the Court finds that Petitioner has established its right to a preliminary injunction: (1) The injunction is necessary to prevent immediate and irr parable harm to Petitioner that cannot be adequately compensated by d ges; (2) Greater injury would result from refusing Petitioners request for an injunction, and the issuance of an injunction will not su stantially harm Respondent; (3) A preliminary injunction will properly restore the pantie to their status quo as it existed immediately prior to Respondent's breach of her statutory duty to support her mother, Ms. Freeman, an Respondent's breach of her contractual duties pursuant to the Agreemen she signed; (4) Petitioners right to relief from Respondent's breach of he statutory duty to support her mother and from Respondent's breach of her contractual duties is clear; (5) The injunction Petitioner seeks is reasonably suited and and breadth to abate the existing activity; and in scope (6) The injunction is in the public's interest. .' It is ORDERED AND DECREED that Respondent is directed t cooperate with Petitioners efforts to secure Medical Assistance benefits on her mother's behalf. The cooperation specifically includes providing any and all financial record application and appeal process within five (5) days of the date of this c any and all other actions necessary to obtain benefits for her mother. PO SO IUD r S?a`1 LC 1YhvIrLI eY- r {?e P /l> -..-7,i BY THE COURT: i 0 needed for the and taking 1? N lam} ?;: ? LaJ ..._ i BEVERLY ENTERPRISES, IN THE COURT OF COMMON PLEAS OF INC., DB/A WEST SHORE CUMBERLAND COUNTY, PENNSYLVANIA HEALTH AND REHABILITATION CENTER, Plaintiff V. : CIVIL ACTION - LAW DOROTHY SCOTT, Defendant NO. 06-6967 CIVIL TERM IN RE: PETITION FOR PRELIMINARY INJUNCTION AMENDED ORDER OF COURT AND NOW, this 8th day of May, 2007, the prior order of court issued in this matter on May 7, 2007, is amended to reflect that a bond of $10.00 shall be required of the Plaintiff. In all other respects, the order shall remain in full force and effect. BY THE COURT, radley A. Schutjer, Esq. Maria Macus-Bryan, Esq. 305 N. Front Street Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff orothy Scott 242 Woodbine Street Harrisburg, PA 17110 Defendant, pro Se :rc J. esley Oler, ., j.- P, S .7 ' u 6- ),x'14 t00Z IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 06-6967 AFFIDAVIT OF SERVICE Beverly Enterprises, Inc., DB/A West Shore Health and Rehabilitation Center vs. Dorothy Scott Commonwealth of Pennsylvania County of Dauphin so. I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that at 8:29 PM on 05/11/2007, I served Dorothy Scott at 242 Woodbine Street, Harrisburg, PA 17110 in the manner described below: ® Defendant(s) personally served. ? Adult family member with whom said Defendant(s) reside(s). Relationship is ? Adult in charge of Defendant(s) residence who refused to give name and/or relationship. ? Manager/Clerk of place of lodging in which Defendant(s) reside(s). ? Agent or person in charge of Defendant's office or usual place of business. an officer of said Defendant's company. ? Other: a true and correct copy of Order of Court, Amended Order of Court issued in the above captioned matter. Description: Sex: Female - Age: 50 - Skin: Black - Hair: Gray - Height: 5' 081; - Weight: 140 Swox to and su sc ed ore me on this j Shinkowsky day of 20Af S nkowsky Ines g ions 316 Fawn Ridge or Harrisburg, PA 1 110 (800) 276-0202 OTARY PUBLIC Atty File#: 06-6967 - Our File# 1119 Law Firm: Schutjer Bogar LLC Address: 305 North Front Street, Suite 401, Harrisburg, PA, 17101 Telephone: (717) 909-5925 COMMGNWEALTH OF RCNNSYLVANI A NOTARIAL SL CAROL L. KENLEY Notary Public Susquehanna Twp., Dauphin County 11 my Commission Expires Nov. 9, 2008 ORIGINAL O ('D ?J `T-. IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/ B/ A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. No. 06-6967 Civil Term DOROTHY SCOTT, Defendant. CIVIL ACTION - EQUITY PLAINTIFF'S MOTION FOR CIVIL CONTEMPT AND NOW, COMES, Beverly Enterprises, Inc. d/b/a West Shore Health and Rehabilitation Center ("Petitioner"), by and through its attorneys, SCHUTJER BOGAR LLC, and files this Motion for Civil Contempt and, in support thereof, avers: 1. On May 7, 2007, this Court entered the Order attached as Exhibit "A." 2. Pursuant to the attached Order, Dorothy Scott ("Respondent") was required, within five (5) days of the date of the Order, to cooperate with Petitioner's efforts to secure Medical Assistance benefits on her mother's behalf, such cooperation specifically including providing any and all financial records needed for her mother's Medical Assistance application and appeal process within five (5) days of the date of the Order. 3. On May 11, 2007, Respondent was personally served with the Order. See Affidavit of Service attached as Exhibit "B." ORIGINAL 4. Respondent has not produced the financial records to the Cumberland County Assistance Office that are needed for the pending Medical Assistance application that was filed on behalf of Respondent's mother. 5. An appeal of the denial of Respondent's mother's Medical Assistance application is currently pending before the Bureau of Hearing and Appeals of the Department of Public Welfare of the Commonwealth of Pennsylvania. 6. A hearing on the aforementioned appeal was scheduled for May 14, 2007, but Petitioner requested and received a 30-day continuance of that hearing to afford Respondent sufficient time to comply with the Order attached as Exhibit "A." 7. If Respondent does not produce the documents requested by the Cumberland County Assistance Office prior to or at the time of the rescheduled hearing, the appeal will be denied, and Petitioner's ability to secure payment for the services it provided to Respondent's mother will be forever lost. 8. In accordance with Cumberland County Local Rule 208.3(a)(9), to the best of Petitioner's knowledge, information, and belief, Respondent has not retained counsel of record, and to date, Petitioner has not received a Entry/ Notice of Appearance of counsel of record for Respondent. 2 WHEREFORE, Plaintiff respectfully requests that this Court issue a decree ordering Respondent to produce the documents requested by the Cumberland County Assistance Office within five (5) days of the date of the service of such a decree and to pay to Petitioner the attorney's fees and costs incurred in seeking relief from Respondent's contempt of this Honorable Court, or suffer the sanction of incarceration for such time as this Honorable Court directs. Dated: 67 , oO Respectfully submitted, SCHUTJER BOGAR LLC By: Bradley A. Schutjer Attorney I.D. No. 75954 (717) 909-5921 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 305 North Front Street, Suite 401 Harrisburg, PA 17101 Attorneys for Plaintiff EXHIBIT,','A"" . t I i J i V L V V I\ I ''w / VV - J J INC., D/B/A WEST SH.OR.E HEALTH AND REHABILITATION CENTER., Plaintiff V. DOROTHY SCOTT, Defen.dan.t j-;r COURT ',: "?ON PJJF , CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION -LAW NO. 06-6967 CIVIL TERM IN RE: PETITION FOR PRELIMINARY INJUNCTION AMENDED ORDER OF COURT AND NOW, this 8"' day of May, 2007, the prior order of court issued in this matter on May 7, 2007, is amended to reflect that a bond of $10.00 shall be required of the Plaintiff. In all other respects, the order shall remain in full force and effect. BY THE COURT, Bradley A. Schutjer, Esq. Maria Macus-Bryan, Esq. 305 N. From Street Suite 401 Harrisburg, PA 171.01 Attorneys for Plaintiff Dorothy Scott 242 Woodbine Street Harrisburg, PA 171 10 Defendant, pro Se :rc i i inA .l. esley Oler, j., r uui Kx udrei 1 1 me tin7- i u-cuu Mnu) uo: ,-l r ?1L1?(:?-:r1=FIC;? THC Pr?,T?Inr'i?TA?Y 29P MAY -9 2_- 51 N.uu? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/ B/ A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. DOROTHY SCOTT, Defendant. C) r-D o No. 06-6967 Civil Term r CIVIL ACTION - EQUITY And now, the -'71 day of 2007, the Court finds that Petitioner has established its right to a preliminary injunction: (1) The injunction is necessary to prevent immediate and irreparable harm to Petitioner that cannot be adequately compensated by damages, (2) Greater injury would result from refusing Petitioner's request for an injunction, and the issuance of an injunction will not substantially harm Respondent; (3) A preliminary injunction will properly restore the parties to their status quo as it existed immediately prior to Respondent's breach of her statutory duty to support her mother, Ms. Freeman, and Respondent's breach of her contractual duties pursuant to the Agreement she signed; (4) Petitioner's right to relief from Respondent's breach of her statutory duty to support her mother and from Respondent's breach of her contractual duties is clear; (5) The injunction Petitioner seeks is reasonably suited and limited in scope and breadth to abate the existing activity; and (6) The injunction is in the public's interest. It is ORDERED AND DECREED that Respondent is directed to cooperate with Petitioner's efforts to secure Medical Assistance benefits on her mother's behalf. The cooperation specifically includes providing any and all financial records needed for the application and appeal process within five (5) days of the date of this order and taking any and all other actions necessary to obtain benefits for her mother. rf o R->o ao D Sln ?? b e 1Y v ?r 1 c 1 7 I BY THE COURT: EXHIBIT,I,IB4"l' IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CASE NO.: 06-6967 AFFIDAVIT OF SERVICE Beverly Enterprises, Inc., DB/A West Shore Health and Rehabilitation Center vs. _ 0 -n -_? --4 -7 Dorothy Scott Commonwealth of Pennsylvania County of Dauphin SS. -? -r= I, John Shinkowsky, a competent adult, being duly sworn according to law, depose and say that a f-8:29 PM o ? 05/11/2007, I served Dorothy Scott at 242 Woodbine Street , Harrisburg, PA 17110 in the man 7-Y desefibed below: 1-0 ® Defendant(s) personally served. ? Adult family member with whom said Defendant(s) reside(s). Relationship is ? Adult in charge of Defendant(s) residence who refused to give name and/or relationship. ? Manager/Clerk of place of lodging in which Defendant(s) reside(s). ? Agent or person in charge of Defendant's office or usual place of business. ? Other: an officer of said Defendant's company. a true and correct copy of Order of Court, Amended Order of Court issued in the above captioned matter. Description: Sex: Female - Age: 50 - Skin: Black - Hair: Gray - Height: 5' 08" - Weight: 140 Swox to and su sc . ed ore me on this day of 20P9.' ROTARY PUBLIC X 1- m Jqtlh Shinkowsky S nkowsky Ines g ions 316 Fawn Ridge or Harrisburg, PA 1 110 (800) 276-0202 Atty File#: 06-6967 - Our File# 1119 Law Firm: Schutjer Bogar LLC Address: 305 North Front Street, Suite 401, Harrisburg, PA, 17101 Telephone: (717) 909-5925 COMMONWEALTH OF PENNSYLVANIA SEA Susqu LN KENLiEY, ' Notary Public FCAROhenn a Twp. , Dauphin County My Commission Expires Nov. 9, 2008 COPY CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Plaintiff's Motion for Civil Contempt, Proposed Order, and Brief in Support of Motion for Civil Contempt was served via first-class, United States mail, postage prepaid, upon the following: Dorothy Scott 242 Woodbine Street Harrisburg, PA 17110 Dated: 2 y? By: William Keslar, Paralegal r`a? ? 7 ! ? ? ---° , i ? A f ! V y _. ? .. • • ., i w.? IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/ B/ A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. DOROTHY SCOTT, Defendant. ORDER No. 06-6967 Civil Term MAY 89W0? CIVIL ACTION - EQUITY AND NOW, this t Si __ , day of ?T,Lb L , 2007, a hearing in the above-captioned matter on the motion for civil contempt is scheduled for 4?? " r , 2007, at J -,&.m. in Court Room No. Cumberland County Courthouse, One Courthouse Square, Carlisle, Pennsylvania 17013. ORIGINAL BY THE COURT: N C7 C' N U BEVERLY ENTERPRISES, INC. IN THE COURT OF COMMON PLEAS OF D/B/A WEST SHORE HEALTH AND CUMBERLAND COUNTY, PENNSYLVANIA REHABILITATION CENTER, Plaintiff V. CIVIL ACTION - LAW DOROTHY SCOTT, Defendant NO. 06-6967 CIVIL TERM ORDER OF COURT AND NOW, this 8th day of June, 2007, in consideration of Plaintiff's Motion for Civil Contempt and upon hearing thereon at which Defendant did not appear and at which evidence was presented in support of the motion for contempt, the Plaintiff's Motion For Civil Contempt is granted and the Defendant is adjudicated in civil contempt. It is hereby ordered and decreed that Defendant shall provide no later than five days from the date of service of this order by ordinary mail to the Cumberland County Assistance Office those documents necessary for determination as to the eligibility of Gertrude Freeman for medical assistance benefits. In the event that the Defendant does not comply with this order, the Court will entertain a motion for her incarceration. Maria Macus-Bryan, Esquire 305 N. Front Street Ste 401 Harrisburg, PA 17101 For the Plaintiff orothy Scott 242 Woodbine Street Harrisburg, PA 17110 For the Defendant pcb By the Court, 1 ! C f In LOOZ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. d/ b/ a WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. DOROTHY SCOTT, Defendant. No. 06-6967 Civil Term : CIVIL ACTION - EQUITY AFFIDAVIT OF SERVICE I, William Keslar, being duly sworn according to law, depose and say that I served Defendant Dorothy Scott with the attached Order of Court dated June 8, 2007, in the above-captioned matter, via First-Class Regular Mail, to her residence at 242 Woodbine Street, Harrisburg, PA 17110 on the 2061 day of June, 2007. Dated: Sworn to and Subscribed before me this day of 2007. et&4 I 6?iw_ I Notary an, My Co on Expires: ?- or torgn.y NOTARIAL SEAL CHRISTY A. LONG, Notary PW* City of Harrisburg, Dauphin Cowy Commission Ex ires Deoernber 2= V? William Keslar, Paralegal ORIGINAL BEVERLY ENTERPRISES, INC. IN THE COURT OF COMMON PLEAS OF D/B/A WEST SHORE HEALTH AND CUMBERLAND COUNTY, PENNSYLVANIA REHABILITATION CENTER, Plaintiff V. CIVIL ACTION - LAW DOROTHY SCOTT, Defendant NO. 06-6967 CIVIL TERM ORDER OF COURT AND NOW, this 8th day of June, 2007, in consideration of Plaintiff's Motion for Civil Contempt and upon hearing thereon at which Defendant did not appear and at which evidence was presented in support of the motion for contempt, the Plaintiff's Motion For Civil Contempt is granted and the Defendant is adjudicated in civil contempt. It is hereby ordered and decreed that Defendant shall provide no later than five days from the date of service of this order by ordinary mail to the Cumberland County Assistance Office those documents necessary for determination as to the eligibility of Gertrude Freeman for medical assistance benefits. In the event that the Defendant does not comply with this order, the Court will entertain a motion for her incarceration. By the Court, Maria Macus-Bryan, Esquire 305 N. Front Street Ste 401 Harrisburg, PA 17101 For the Plaintiff Dorothy Scott 242 Woodbine Street Harrisburg, PA 17110 For the Defendant pcb c tx ?- M;p cr, +?l.?... i l rn tt5 ! w„ IN THE COURT OF COMMON PLEAS CUMBERLAND COUNTY, PENNSYLVANIA BEVERLY ENTERPRISES, INC. D/ B/ A WEST SHORE HEALTH AND REHABILITATION CENTER, Plaintiff, V. DOROTHY SCOTT, Defendant No. 06-6967 Civil Term CIVIL ACTION - EQUITY PRAECIPE TO WITHDRAW, DISCONTINUE AND END To the Prothonotary: Kindly mark the above-captioned action withdrawn, discontinued and ended. Respectfully submitted, SCHUTJER BOGAR LLC Dated: 2 By: Bradley A. Schuger Attorney I.D. No. 75954 Maria G. Macus-Bryan Attorney I.D. No. 90947 (717) 909-8640 305 North Front Street, Suite 401 Harrisburg, PA 17101 Fax No.: (717) 909-5925 Attorneys for Plaintiff ORIGINAL i ? CERTIFICATE OF SERVICE I hereby certify that a true and correct copy of the foregoing Praecipe to Withdraw, Discontinue and End was served via first-class, United States mail, postage prepaid, upon the following: Dorothy Scott 242 Woodbine Street Harrisburg, PA 17110 Dated: G At s /'P By: William Keslar, Paralegal ?A t L rin # C:7: fli.13 s s`?J f C! t :' ,....1 tom} C?1 . 4 } ? y . . T