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HomeMy WebLinkAbout02-2835HCR MANORCARE, INC., Plaintiff, VS. STEWART STRINE, JR. and JOHN D. STRINE, individually and as attorney-in-fact for STEWART STRINE, JR., Defendants. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL ACTION-EQUITY COMPLAINT NOW, comes Plaintiff, HCR ManorCare, Inc. ("Manor"), by and through its attorneys, O'BRIEN, BARIC & SCHE1LER, and files the within complaint and, in support thereof, sets forth the following: 1. HCR ManorCare, Inc. is an Ohio corporation, duly authorized to conduct business in the Commonwealth of Pennsylvania with an office located at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 2. Defendant, Stewart Strine, Jr., is an adult individual with a last known address of 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. 3. Defendant, John D. Strine, is an adult individual with a last known address of 283 Meadow Road, Newville, Cumberland County, Pennsylvania 17241. 4. Manor operates a skilled nursing facility located at 940 Walnut Bottom Road, Carlisle, Cumberland County, Pennsylvania 17013. SHERIFF'S RETURN - ~A~E NO: 2002-02835 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANORCARE INC VS STRINE STEWART JR ET AL REGULAR~,,~ RONALD HOOVER , Sheriff or Deputy Sheriff of Cumberland County,Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT - EQUITY was served upon STRINE JOHN D the DEFENDANT , at 1058:00 HOURS, on the 19th day of June at 283 MEADOW ROAD , 2002 NEWVILLE, PA 17241 by handing to MARSHALL WILSON, ~dDULT FRIEND a true and attested copy of COMPLAINT - EQUITY together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 6.00 Service 11.04 Affidavit .00 Surcharge 10.00 .00 27.04 Sworn and Subscribed to before me this 2V ~ day of A.D. 'P~othonotary ' ~ So Answers: R. Thomas Kline 06120/2002 OBRIEN BARIC SCHERER By: Deputy Sheriff SHERIFF'S QKSE NO: 2002-02835 P COMMONWEALTH OF PENNSYLVANIA: COUNTY OF CUMBERLAND HCR MANORCARE INC VS STRINE STEWART JR ET AL RETURN - REGULAR DOUGLAS DONSEN , Sheriff or Deputy Sheriff of Cumberland County, Pennsylvania, who being duly sworn according to law, says, the within COMPLAINT - EQUITY was served upon STRINE STEWART JR the DEFENDANT , at 0940:00 HOURS, on the 12th day of June at 940 WALNUT BOTTOM ROAD , 2002 CARLISLE, PA 17013 STEWART STRINE JR by handing to a true and attested copy of COMPLAINT - EQUITY together with and at the same time directing His attention to the contents thereof. Sheriff's Costs: Docketing 18.00 Service 3.45 Affidavit .00 Surcharge 10.00 .00 31.45 Sworn and Subscribed to before me this Jg ~ day of D. ' ~rothonotary ' ' So Answers: R. Thomas Kline 06/20/2002 OBRIEN %~U~g~ahse r~en 5. On or about August 13, 2001, Stewart Strine, Jr. sought to be admitted to the Manor facility to obtain skilled nursing care. In connection with his admission to the facility, John D. Strine executed an Admission Agreement ("Admission Agreement"). A tree and correct copy of the Admission Agreement is attached hereto as Exhibit "A" and is incorporated. 6. John D. Strine, in executing the Admission Agreement, represented that he "...has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center." Admission Agreement ¶2.01 Further, John D. Strine became the attorney-in-fact for Stewart Strine, Jr. by virtue of a Power of Attorney, a true and correct copy of which is attached hereto as Exhibit "B" and is incorporated. 7. The Admission Agreement bound Stewart Strine, Jr. to pay for the costs of his care while a resident of the facility. 8. Stewart Strine, Jr. became a resident of the facility on or about August 13, 2001 and remains a resident to the date hereof. 9. On or about August 13,2001, John D. Strine completed an Application for Residency seeking admission of Stewart Strine, Jr. to the facility. A true and correct copy of the Application for Residency is attached hereto as Exhibit "C" and is incorporated. 10. John D. Strine represented on the Application for Residency that as of the time of completing the application, Stewart Strine, Jr. would be receiving social security benefits. 11. The Admission Agreement bound John D. Strine to pay from the assets and income of Stewart Strine, Jr., sums due for the costs of care not covered by a third party payor. 2 12. Upon information and belief, at all times since the admission of Stewart Slxine, Jr. to the facility, John D. Strine has been receiving the social security benefits of Stewart Strine, Jr.. 13. Despite demand therefore, neither John D. Strine nor Stewart Strine, Jr. has paid ManorCare for all of the costs of care accruing. 14. As of April 30, 2002, the sum of $5,245.00 remains due and owing for the costs of Stewart Strine, Jr.'s care at the facility. Attached hereto as Exhibit "D" is a true and correct copy of a statement itemizing the amount due and owing. 15. The Admission Agreement provides for the imposition of interest on past due balances at the rate of 18% per annum or 1.5% per month. Interest on the outstanding indebtedness to Mayl5, 2002 is $229.62 and continues to accrue at the rate of $2.58 per diem. 16. The Admission Agreement provides for the recovery of attorney fees incurred by ManorCare in the collection of a debt due and owing. COUNT I- BREACH OF CONTRACT HCR MANORCARE v. STEWART STRINE, JR. and JOHN D. STRINE 17. Plaintiff incorporates by reference paragraphs one through sixteen as though set forth at length. 18. All conditions precedent to recovery under the Admission Agreement have been met. 19. John D. Shrine was obligated to use the assets and income of Stewart Shine, Jr. to satisfy the debt due and owing to ManorCare for services and care provided to Stewart Shine, Jr. by ManorCare. Further, John D. Shine agreed that he would take no action to dissipate any of the assets of Stewart Strine, Jr. which could be used to pay for the costs of his care at the ManorCare facility. 20. Demand has been made upon John D. Shine to pay the outstanding debt. 21. John D. Shine has, without justification, failed and refused to pay for the costs of care provided to Stewart Strine, Jr.. Stewart Strine, Jr. agreed to pay for the costs of his care at the facility. Demand has been made upon Stewart Strine, Jr. to pay for the costs of his care at 22. 23. the facility. 24. of his care. 25. Stewart Shine, Jr. has, without justification, failed and refused to pay for the costs John D. Slrine and Stewart Shine, Jr. have breached the Admission Agreement. WHEREFORE, Plaintiff requests judgment in its favor and against the Defendants for the sum of $5,474.62 plus interest to the date of award, interest, costs and expenses and attorney fees. 4 length. 26. COUNT II- MONEY HAD AND RECEIVED HCR MANORCARE, INC. v. JOHN D. STRINE Plaintiff incorporates paragraphs one through twenty-five as though set forth at 27. During the period of Stewart Shine, Jr.'s residency at the facility John D. Shine has received the social security benefits payable to Stewart Strine, Jr. in an amount believed to be in excess of $7,240.00. 28. The proper use of these funds received by John D. Strine would have been to pay the costs accruing for the care of Stewart Strine, Jr. at the ManorCare facility. 29. At the time of receipt of these funds, John D. Shine knew that he was obligated to pay those funds over to ManorCare for the costs of Stewart Shine, Jr.'s care at the facility. 30. John D. Strine gave no consideration for the funds of Stewart Shine, Jr. received by John D. Shine. 31. Demand has been made upon John D. Strine to tender the funds of Stewart Strine, Jr. to ManorCare which he has failed and refused to do. WHEREFORE, Plaintiff requests judgment in its favor and against John D. Shine requiting John D. Strine to: a) return the subject matter in specie; b) pay over the value if he has consumed the money in beneficial use; c) pay its value if he has disposed of the funds received; and, d) award attorney fees, costs and expenses and interest. 32. COUNT III- QUANTUM MERUIT HCR MANORCARE, INC. v. STEWART STRINE, JR. Plaintiff incorporates paragraphs one through thirty-one as though set forth at 33. Stewart Stfine, Jr. used and enjoyed the services provided to him by ManorCare during the period of his residency at the ManorCare facility. 34. Stewart Strine, Jr. used and enjoyed these services provided to him by ManorCare without making payment for those services and he has been unjustly enriched thereby. WHEREFORE, Plaimiff requests judgment in its favor and against Stewart Strine, Jr. for the value of the services rendered to him plus attorney fees, costs and expenses and interest. Respectfully submitted, David A. Bade, Esquire I.D. # 44853 17 West South Street Carlisle, PA 17013 (717) 249-6873 Attorney for Plaintiff dab.dir/manor/strine/complaint, pld 85/31/2882 16:21 7172495755 OBS LAW OFFICE PAGE I verify that the statements made in the forcgoi~ Compla~t a~e tr~e and correct. ! understand that false statemeats h~in are made subject to the penalties of 18 Pa. C.S. § 4904, relating to unswom ~alsification to authorities. - Kimb~y Etzler U Business Office Manger HCR Manor Cari~.- . ADMISSION AGREEMENT This Agreement is entered into by and among HCR Manor Care, the Resident, and the Legal Representative, for the purpose of providing for the rights and responsibilities of the parties with respect to the Resident's stay at this HCR Manor CarPs Health Care Center ("Center"). Center: t4~. ~ //~/~.f (' C~.~ "(C · . + ' Resident: - C.~ x~ O 'r ' - "l - I lq ~C. Legal Representative: Admission Date: r~, / [ ,~,10 / Deposit: $ ~ Term: This Agreement shall begin on the day the Resident enters the Center and end on the day the Resident is discharged. I. RIGHTS AND RESPONSIB]]LITHgS OF THE RESIDENT 1.01 Room and Boated Rate. For the basic services provided for in Section 3.01, the Resident agrees to pay the applicable Room and Board Rate set forth on Attachment A hereto. The Room and Board Rate is subject to change upon thirty (30) days written notice. The Room and Board Rate set forth in Attachment A is payable in advance and'is due by the tenth (10th day of each month. The Resident shall be responsible for the Room and Board Rate for the day of admission as well as the day of discharge. This Section shall not apply if the Resident is covered under a Governmental Program (see Section 1.05) or by a Third Party Payor or Managed Care Organization (see Section 1.06). 1.02 ~. The Resident further agrees to pay to the Center all charges for additional medical, therapeutic, or personal care services or supplies that may be requested by the Resident, ordered by the attending physician, or provided in the Resident's Plan of Care. The Center reserves the right to charge for personal care items of the Resident if necessary for the well-being of the Resident. Such "Ancillary Charges" are described on Attachment B hereto, and a current ancillary charge list is maintained at the Center's business office for review during regular business hours. Ancillary Charges shall be included in the Resident's statement for the succeeding month, and are payable in full, along with the Room and Board Rate by the tenth (10th day of the month. EXHIBIT "A" · 1.03 ~. Accounts not paid in full within thirty (30) days of billing shall be --.. subject to a service charge equal to the highest legal rate of interest permitted by State law as set forth in Attachment A on the past due balance each month until such time as the balance due is paid in full. Should the Resident's account for any reason be turned over for collection, the Resident agrees to pay the Center's collection costs, including attorney's fees. 1.04 Independent Providers. The Resident shall be directly responsible to independent providers, including but not limited to, the Resident's attending physician for any health or personal program in accordance with the terms of the program. 1.05 Governmental Programs. If the Resident is eligible for coverage under any governmental program, such as Medicare, Medicaid, or through the Veterans Administration, and the Center participates in such program, the Center shall accept payments under such program in accordance with the terms of the program on the contract the Center has with the program. The Resident shall be responsible for any co-insurance, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. The Resident must comply with all program requirements. In the event the Resident's coverage under the governmental program(s) cease for any reason, the Resident will be charged at the Center's rate for private pay residents in accordance with Sections 1.01 and 1.02. The Center participates in the following programs: ..Medicare, Medicaid and/or VA. Medicare may pay for some or all of the Kesident's care. If Medicare agrees to pay for the Resident's care, there is a required co-payment, which Medicare updates yearly. If the Resident also participates in Medicare Part B, for physical, occupational, or speech therapy or other billable charges (which are not covered by Medicare Part A), the Resident and/or Legal Representative agree to pay any required deductible, any required co-insurance, and any non-covered services according to the same terms and conditions applicable to private pay residents. For Medicaid, see Attachment L for additional information. The Resident and/or Legal Representative are responsible for applying for Medicaid. If the Resident receives Medicaid, most of the Center charges such as Room and Board and nursing services are covered, although Medicaid may require the Resident to pay a portion of the Room and Board Rate from their monthly income. The Resident and/or Legal Representative agree to pay on a timely basis, as set forth in this Agreement, the contribution amount as determined and periodically adjusted by the State and/or local department(s) handling Medicaid. If the Resident and/or Legal Representative fail to pay the contribution amount, the Center may take such legal action as necessary, including requesting a court to order such payment. 1.06 Third Party Payors and Managed Care Organizations. If a Resident is a participant in a plan offered by a third party payor such as a Health Maintenance Organization ("HMO"), Preferred Provider Organization ("PPO'), Provider Sponsored Organization ('PSO'), or Physician Hospital Organization ('PHO'), indemnity plan or another similar entity with which the Center has executed a provider agreement, the charges are governed by the applicable agreement. The Resident shall be responsible for any co-payments, deductibles or non-covered charges, according to the same terms and conditions applicable to private pay residents. If the Center has not executed a provider agreement with the Resident's third party payor, the Center will bill the Resident's third' party payor as a service, but the Resident remains liable for charges not paid or covered by that third party payor including charges not paid within a reasonable period of time. 1.07 Private Pay Resident. The Resident and/or Legal Representative acknoMedge that they are responsible for paying the Center for items and services provided during the stay at the Center and during which time the Resident has not been determined to be eligible for Medicaid. The Resident and/or Legal Representative agree to notify the Center promptly if there is insufficient income or assets to meet the financial obligations to the Center or to make prompt application to Medicaid for benefits. The Resident and/or Legal Representative agree to notify the Center in writing when application to Medicaid is made. The Resident and/or Legal Representative agree to cooperate fully in applying for Medicaid and in the eligibility determination process. If the Resident is no longer able to pay for care at the Center and the Resident is not eligible for Medicaid, the Resident will be notified of the Center's intention to discharge the Resident for non-payment in accordance with the Agreement, Resident Handbook and State and federal laws. 1.08 Admission Information. It shall be the responsibility of the Resident and/or Legal Representative to notify the Center and to provide any needed information regarding all third party payors or governmental coverages on admission and throughout the stay including copies of insurance cards, identification or verification of eligibility and coverage information. The Resident and/or Legal Representative agree to provide the Center with notice within five (5) days of the Resident's disenrollment, enrollment, change in health care coverage, failure to pay premium(s) or renewal of insurance coverage and any cancellations in coverage as the Center relies on the information supplied regarding such coverage. The Resident and/or Legal Representative acknowledge that if they fail to provide such information, they may be responsible for any denied charges due to lack of authorization, ineligibility, non-coverage or other costs associated with the failure to provide such notice in accordance with the terms and conditions of this Agreement. 1.09 A lication for Benefits. It shall be the responsibility of the Resident and/or Legal Representative to apply for coverage and to establish eligibility under any governmental, third party payor, managed care or private insurance program. The Center shall be under no obligation to bill any third party payor other than the Legal Representative and, when applicable, a governmental program third party payor or managed care organization with which the Center is under contract. 1.10 Primary_ Responsibility for Payment. Except for payments for services covered under governmental programs or provider agreements, the Resident shall remain primarily liable for any and all charges for which the Center may agree to bill a third party. The Resident and/or Legal Representative acknowledge that the insurance company, HMO, PPO, PSO, PHO or managed care provider may not pay for non-covered services, supplies, equipment, medications, and other care and services which may be delivered by the Center or its subcontractors. This Agregment serves as a written notice that the Center has notified the Resident and/or Legal Representative that services provided at the Center may not be covered by a governmental payor, third party payor or managed care organization. The Resident and/or Legal Representative agrees to be responsible for non-covered services. A price list of services is always available at the business office upon request. IA1 Personal Physician. The Resident has the right to choose a personal physician, provided that the physician selected is properly licensed and agrees to abide by applicable law and the roles and policies of the Center. At the time of admission, the Resident must supply the Center with the name of his/her personal physician. If the Resident changes physicians at any time after admission, the Resident and/or Legal Representative must immediately notify the Center of the new physician's name. If the physician chosen by the Resident fails to provide needed coverage and attendance or fails to abide by applicable laws and regulations, the Center shall have the right to call another physician to attend the Resident and the fees charged by such physician shall be borne by the Resident. 1.12 Pharmacy. The Resident and/or Legal Representative acknowledge the right to choose a pharmacy of choice, provided the pharmacy selected is properly licensed, packages and supplies pharmaceuticals in accordance with State law and agrees to abide by the Center's policies and procedures and the pharmacy has a medication distribution system similar to the Center's ancillary pharmacy's medication distribution system. II. RIGHTS AND RESPONSIBILITY OF TIlE LEGAL REPRESENTATIVE 2.01 ~. The Legal Representative hereby represents that he/she has legal access to the Resident's income or resources and that the documents supporting such authority, if any, have been delivered to the Center. 2.02 Agreement to Make Payments on Behalf of Residenl[. The Legal Representative agrees to pay promptly from the Resident's income or resources all fees and charges for which the Resident is liable under this Agreement. The Legal Representative shall not incur personal liability on behalf of the Resident except for a breach of the duty to provide payment from the Resident's income or resources for the fees and charges provided for in this Agreement. 2.03 ~ Items. The Legal Representative shall be personally liable for any services or products specifically requested by the Legal Representative to be supplied to the Resident, unless such services or products are covered by a governmental program. 2.04 Exhaustion of Resident's Funds. If the Resident's financial resources change such that the Resident may be eligible for Medicaid, the Resident and/or Legal Representative must notify the Center in writing when the application for Medicaid is made. If the Legal Representative fails to notify the Center in writing or fails to file for Medicaid in a timely and proper manner, the Legal Representative shall be personally liable for all charges and fees not covered by Medicaid which otherwise would have been covered had application been made in a timely and proper manner. · 2.05 Cooperation for~Finaneial Assistance. If the Resident is eligible for Medicaid, the Legal Representative shall provide such information about the Resident's finances as Medicaid representative shall require for continued coverage of the Resident and be personally responsible for any charges denied the Center due to any lack of cooperation. 2.06 Acceptance Upon Discharge. Upon termination of this Agreement as provided in the Resident Handbook, the Legal Representative agrees to arrange and pay for the departure of the Resident from the Center. If after notice the Resident is not removed as requested, then the Center is authorized and empowered to remove the Resident by reasonable means of transportation and to deliver the Resident to the residence address of the Legal Representative, if the Resident's condition permits, who shall unconditionally be obligated to accept the Resident and to pay promptly all charges. 2.07 Additional Responsibilities. The Legal Representative acknowledges the other duties and responsibilities for the Resident and to the Center as set forth in this Agreement and Attachments. RIGHTS AND RESPONSIBILITHgS OF THE CENTER 3.01 Room and Standard Services. As part of the Room and Board Rate, the Center shall furnish basic room, board, common facilities, housekeeping, laundered bed linens and bedding, general nursing care, personal assessment, social services, and such other personal services as may be required pursuant to the plan of care prepared by the Resident's physician and the Center, with the Resident's consent, for the health, safety and general well-being of the Resident. 3.02 Other Services. The Center shall act in accordance with the Resident Handbook, which is incorporated by reference in this Agreement. 3.03 Deposit. The Center hereby acknowledges receipt of the Deposit, if any, noted at the beginning of this Agreement. The Deposit shall be applied to the charges for the first month of the Resident's stay at the Center. 3.04 Refunds. Any refund owed to the Resident for advance payments shall be paid by the Center witl~in thirty (30) days after discharge or transfer or within the time frame required by State law. In the case of Medicaid Residents, any such refund shall be paid within thirty (30) days of the Center's receipt of the final Medicaid payment for care of the Resident. IV. GENERAL PROVISIONS 4.01 Consent to Release of Information. The Resident and/or Legal Representative hereby consents to the release of his/her medical records to the following persons: Center personnel, attending physicians and consultants; and person, firm, government entity, third party payor or managed care organization responsible for all or any party of the payment or reimbursement of the Resident's charges, including any utilization review or quality assurance 5 review§ or payment audits performed by such; the personnel of any hospital or other health care facility or provider to whom or which the Resident may be transferred; the Center's liability insurance carrier; and any person authorized by law to review the medical records. 4.02 Consent to Treat. The Resident and/or Legal Representative, by signing this Agreement, hereby authorizes the appropriate staff of the Center to perform such f~nctions, care and services (hereinafter "Treatment") as are necessary to maintain the well-being of the Resident, including but not limited to, assistance with bathing, hygiene, dressing, toiletry, and daily activities; and general nursing care, the administration of medications and treatments, and the performance of therapies, as prescribed by the Resident's personal physician in the Resident's Plan of Care, or as required from time to time in the exercise of good nursing judgment, subject to any rights provided to the Resident by federal and/or state law. As applicable, the undersigned Legal Representative hereby represents that he/she has the legal authority to make health care decisions on behalf of the Resident, that documents supporting such authority have been delivered to the Center, and that such Legal Representative hereby consents on behalf of the Resident to the Treatment described above. 4.03 Consent to Photograph. The Resident and/or Legal Kepresentative agree to consent to the Center taking a photograph of Resident for use in identifying the Resident, for placement of the photograph in the Medication Administration Record or other records and for any other similar uses of the photograph for Center and staff to identify the Resident. 4.04 Notice of Services, Policies and Additional Information. The Resident and/or Legal Representative acknowledge that the items listed below have been explained and have received copies of the items or policies and procedures, if applicable. The Resident and/or Legal Representative acknowledge they have had the opportunity to ask questions and questions have been answered satisfactorily. a. Authorization for Release or Review of Medical Information. See Attachment C. b. Authorization for Payment of Benefits. See Attachment D. c. Social Security Administration Appointment. See Attachment E. d. SNF Medicare Determination Notice. See Attachment F. e. Medicare Secondary Payor Questionnaire. See Attachment G. At the request of the Resident and/or Legal Representative, the Center shall maintain the Resident's personal funds in compliance with the laws and regulations relating to the Center's management of such funds. A description and/or policies and procedures of protection of resident funds and the Personal Trust Fund Agreement, Resident Personal Funds Authorization and any other related documents. See Attachment H-1 and H-2. The Center's policy and procedure on bedholds, election of bedholds and readmission. See Attachment I (Center Supplement). Social Service Agencies and Advocacy Groups addresses and phone numbers. See Attachment I (Center Supplement). Name, address and phone number of Ombudsman. See Attachment I (Center Supplement). The location in the Center where the names, addresses and telephone numbers of state client advocacy groups, state survey and certification agency, the state licensure office, the state ombudsman program, the protection and advocacy network and the Medicaid fraud control unit. See Attachment I (Center Supplement). The name, specialty and way of contacting the attending physician, medical director and other physicians who serve the Center. See Attachment I (Center Supplement). Procedures, name, address and phone number on how to file a complaint with the state survey and certification agency concerning resident abuse, neglect, mistreatment and misappropriation of property. See Attachment'I (Center Supplement). The Resident Handbook. See Attachment J. Resident/Patient Rights. See Attachment K. Medicare/Medicaid information and display of such information including how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments. See Attachment L. Receipt of information on advance directives including a copy of "Refusal of Life Sustaining Treatment", which summarizes HCR Manor Core's Limited Treatment Practices and "No Cardiopulmonary Resuscitation Orders" and a copy of the State summary of its laws governing the Resident's right to direct his/her medical treatment. See Attachment and M-2. Privacy Act Notification. See Attachment N. Inventory sheet and/or policy of personal items. See Attachment O. 7 V. W. X. y. Z. ASM Form. See attachment P. Consent to Photograph See Attachment Q. See Attachment R. See Attachment S. See Attachment T. See Attachment U. See Attachment V. See Attachment W. 4.05 Assignment of Benefits. The Resident and/or Legal Representative hereby requests that payment of authorized government and/or third party payor benefits as described in Sections 1.05 and 1.06, if any, be made as set forth in Attachment D to this Agreement either to me or on my behalf for any service furnished by or in the Center. The Resident and/or Legal Representative hereby authorizes the Center and any holder of medical or other information to release such information to the Health Care Financing Administration and its agents and to third party payors any information needed to determine these benefits or b~nefits for related services. 4.06 Termination, Discharge and Transfer. This Agreement may be terminated as set forth below and as set forth in the Resident Handbook under the Section Heading "Discharge". The Resident and/or Legal Representative may terminate this Agreement before the Resident's discharge from the Center by providing the Center written notice of the Resident's desire to leave at least seven (7) days in advance of the Resident's departure. If the Resident leaves before the end of that time, the Resident must still pay for each day of the required notice unless the Center fills the bed before the end of the notice period. Except in the event of an emergency or death, the Resident shall be responsible for all charges for the Room and Board Rate and for all services performed up to the end of the day that the Admission ends. Discharge from the specialized units such as the Transitional Care Unit or Subacute Unit may require less than seven (7) days notice. If discharge or transfer becomes necessary because the Resident and/or Legal Representative or someone else abused the Resident's funds, the Center will request that local, state and federal authorities, as appropriate investigate, which may result in prosecution. 4.07 Indemnification. The Resident shall defend, indemnify and hold the Center harmless from any and all claims, demands, suit and actions made against the Center by any person resulting from any damage or injury caused by the Resident to any person or the property of any person or entity (including the-Center), except in the case of negligence of the Center's employees and agents. 4.08 Chan~ Law. Any provision of the Agreement that is found to be invalid or unenforceable as a result of a change in State or Federal law will not invalidate the remaining provisions of this Agreement and, it is agreed that to the extent possible, the Resident and the Center will continue to fulfill their respective obligations under this Agreement consistent with the law. THE UNDERSIGNED HEREBY CERTIFY AND ACKNOWLEDGE THAT THEY HAVE EACH READ AND UNDERSTOOD THE FOREGOING AGREEMENT, AND THAT THEY HAVE HAD AN OPPORTUNITY TO ASK QUESTIONS AND THAT ANY SUCH QUESTIONS HAVE BEEN ANSWERED TO THEIR SATISFACTION. Signature of Resident: Date: Signature ofLegalRepresentative, ifsigning onbehalfofResident: Date: Signature of Legal Representative, signing on his/her own behalf: Center Representative: $'TEPI-I~N J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 POWER OF ATTORNEY I, Stewart Strine, of Carlisle, Cumberland County, Pennsylvania, do hereby nominate, constitute and appoint John D. Strine as my true and lawful Attorney-In-Fact to act in my name, place and stead to do and perform any act that I myself might perform if I were personally present in regard to the following: To endorse checks, notes, drafts and any other commercial papers in my name and to withdraw money from any bank accounts that I may have for my benefit, and to sign orders or receipts therefore in my name; To enter into any safe deposit box I may have in my own name or jointly with another person to inventory the contents of such box or to do or perform any act with respect to the contents that I might legally perform if I were personally present; To sell and enter into a contract or contracts for the sale of all or any part of my personal property, effects and belongings of every kind and nature wherever situated for my benefit with full power to deliver possession of said personal property and to execute in my name any documents necessary to transfer title to said personal property, including bills of sale or other documents of title, and to take any security interest for any unpaid balance which my Attorney-In-Fact in his discretion may deem necessary and proper; To borrow money from such sources and on such terms as my Attorney may deem fit and proper, and to execute in conjunction with any loan of money a security agreement covering any of my real or personal property and to execute, sign, acknowledge and deliver in any form that instrument that may be required in conjunction with the transaction; To authorize my admission to medical, nursing, residential or similar facility and to enter into agreements for my care. This power is to be construed and implemented in accordance with the provisions of Chapter 56 of Title 20, Consolidated Pennsylvania Statutes in effect on the date of execution of this Power of Attorney; To authorize medical and surgical procedures. This power is to be construed and implemented in accordance with the provisions of Chapter 56 of Title 20, Consolidated Pennsylvania Statutes in effect on the date of execution of this Power of Attorney. EXHIBIT "B" NOTICE The purpose of this Power of Attorney is to give the person you designate (Your "Agent") broad powers to handle your property, which may include powers to sell or otherwise dispose of any real or personal property without advance notice to you or approval by you. This Power of Attorney does not impose a duty on your agar~t to exercise granted powers, but when powers are exercised, your agent must use due care to act for your benefit and in accordance with this power of attorney. Yr~ur agent may exercise the powers given here throughout your lifetime, even after you become incapacitated, unless you expressly limit the duration of these powers or you revoke these powers or a Court acting on your behalf terminates your agent's authority. Your agent must keep your funds separate from your agent's funds. A Court can take away the powers of your agent if it finds your agent is not acting properly. The powers and duties of an agent under a power of attorney are explained more fully in 20 Pa. C.S. Ch. 56 If there is anything about this form that you do not understand, you should ask a lawyer of your own choosing to explain it to you. I have read or had explained to me this notice and I understand its contents. Ste~vart Strine ,"Jt~PI-EEN J. HOGG 19 S. HANOVER STRE ET SUITE 101 CARLISLE, PA 17013 ACKNO~ZVEEDG EMENT I, John D. Strine, have read the attached Power of Attorney and am the person identified as the agent for the principal. I hereby acknowledge that in the absence of a specific provision to the contrary in the Power of Attorney or in 20 Pa. C.S. when I act as agent: I shall exercise the powers for the benefit of the principal. I shall keep the assets of the principal separate from my assets. shall exercise reasonable caution and prudence. I shall keep a fult and accurate record of all actions, receipts and disbursements on behalf of the principal. J~hn D. ,Strine Dat~ ~ STEPHEN J. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 I direct that this Power of Attorney shall be a durable Power of Attorney and shall become effective immediately. Date: STEWART STRINE / ~itness // iTEPI-IEN ~. HOGG 19 S. HANOVER STREET SUITE 101 CARLISLE, PA 17013 ~~.~_~._~ ~. ..... To apply for admission to our'Nursing Center, please complete th~ fdllo~ing questionnaire, sign and return it to the Admissions Office. This application will become a part of the ~Admission Agreement' and should be completed in its entire~. Ali information will be held in confidence. The complete medical histo~ and physical examination results will be recorded on another document. Date: Name of Prospective Residen~Patient: Address:-'q~R'~" ~}-x/~"l;('/-:" 1(~4:{,,' MaritaIStatus: Q M~r~ie~ -QWidowed DS~gle. Telephone No: (7/'7.) 7?~ ~' ~-)': If Married ~r Widowed, Name of Spouse: .:-Soc a 'i (t'4 '_..n q :" l . ' HMO/ins~Jiancei Provider ": .- ' / ':'; '-."ID'~:: ' '-'"' ' .~o~pNo.~ - Medicare No.:" Policy No.: ..:.:... ,,:.......,..: ;: nsuran,c,e is: Q .,P..~ mary¢..Q Sec ndar :' o-in ra ,: . · . ,- ':, "' ~-;'~?.'~:~'::~:.¢'Z: ':;: '~L ¥? :' : :: :~:~:, .-, ;' :,?:,/" '-'-~ ~:~ ¢~,,~,:'/t,' ':7 ' ' .. -' '..' ' . -Nameof'ld~uier?. 'q'~D~,:~i'{,q~, ' . ¥'.'.;,elatl~ns~.i,: .:- --: Other.persons'to contact in.~se o[emergency~., :-:: ,::'..'.;. ;:::~ :,t -..:: :...,,: '': :w.:;;. --x -- ' .... :" e e hone"No' - - --~-'::: ?: -..> ~-: - "". ..... ':Other Phone No.: ...... Flaw did ye. hear'about ".' ~(~.~ - l~L~ ~ ~ ~x ¢ ¢~ · Nurs,ng Center? ' "'~'r---T~'~ ":-.~*' ~ ... ~. .... '-' -'- -: " · , ' " ' , . ' ~:~:-;~;: ~.'~1:':~¢~.? ' ~ Persona Refe~ B Newspaper/Magaz ne · .... ' ' .'" :- ~spta : '' "'.' QTelevisioWRadio'. ' "'"~:"'~': · -' .' ," 'Q'Physiciah .: .... ;-,..' . . ':, .' QYellow. Pages :"'.' ' ..' .{:" :-'.'7':':.",7' ..,' ~. Q Other Profess~na . ' Q ~eath'D~p~rt~nt :' ·-: :,,": .': ,::~ ', t= Q Mailin~Brochure :-. ?..'.-- QSem~nadEvent -. ...... : .... :---;: :'.' ;'..'~ V :' '::."... ,: you Fathers Name. ~ C I~, .' Place of Bidh: City P~~~ Coun~ ~~/~ Sta~e · Ohuroh Preference (optional): · P~ ~ ~ · Preferred Ambulance Company (optional) City. Diagnosis: Current Primary Physician: I~lephone No.:. Tell us about tho ~osid~n~ationt: [ploaso chock all that apply) ~ Montally aloft ~ Ambulatory ~ Confinod to hod ~ Slightly [oroo~ul ~ Walks with assistaneo ~ ~atswith0ut assi~taneo .The fagll!ty [equlre~ .~h~ .a .s~urc~ :of payment be.~de~tlfied to pay for :the Residen~Patienrs 'care.' A ~.~ I . person ;~other.than':th~ resident ~may wish to .be financa y r~Sp~s b e for .the cost '0f 'th6"care Address: · ' · .... · ...... -. Telephone No.: .... ~ -.- Work No.: .... "' - .... --,-,nthe~..No.: ' ~ " '-<: ~h~s person(s) must also complete the "Guaranto~ information and sign the application.) Has a trust ~und boon ostablishod [or tho ~sidon~ationt? ~ Yos ~ Has a Power of ~0r, e~ b~on conferrod on tho p*rs0n(~)to bo fifianeially rosponsi~lo,' or~ porson(s) whO will act on boha [ 0f tho r&s[dont' ('Bospons b o Pa~)? ~ Yos '~o . .' 'If yes, please progide a ~op~;~':' "'~ ': ' '~ " . .... ' ....: . . . .,.~:~. ' " Has a Burial Trust been estabhshed?. Q Yes ~ ........................ I .... ' re uired. The informafior{ supplied is cOhfideritial ~? I '~"~ IlsteO w~etner ii~t=u u.~o~ [ ~~;~bl~ t' *P~.= ~. · r tho Guarantor. All income ~d ~mounts. , . o the Resldent~_~,~t0 pay=~.; ~reciat~ in order to expeu.~ .~,,,,~?~,, .,. ~~?;;l~at a source of payment oe .- · ..... , · HeSlOe~t ~vu ~ , - , ~ . .: - please note that it ~s not man?t~t~ ~n h~ a Guarantor is doing so voluntardy. : .~ identified. Thus, any person wno ag[~ ...... · Cash _ . Checking Savings Money-MarKet ..... .. . Certificates of Deposit'- securities (Stocks/Bonds) . - · Annuities (if not y,e p~Ling ~ . -....~ .? IRA (if not above) '~" Investments/Other '~:, ' '- ,-,uros/unarge Accounts . -". _ Loans..,. . . Other Debts -- _ Taxes Owed -- _. Total Liabilities: ~/-/~,oo NET WORTH: ---(Assets ~ Liabilities) $ .- - $ _ - PLEASE SIGN BELOW: ........ .?:.:.,- I hereby warrant and represent that the information provided is accurate and complete. I ur~derstanc~ inthat the nursingan admissionfaCility willdecision.rely uponl alsothe accuraCYunderstandand completeness cf the above ~inancial information - complete,making the itv will have .~ ,, · ,, relied that if any of the 'in-formatioh iS not accurate of not '-' ""~;~.'-' "~ Facil._..~e,r,mema,y upon the above financial inform~tion and Will sbffer financial loss and harm. The assets listed are in fact available to lhe Resident to pay for th~ Resi care. ~,~.~-~,~ ~, ' - -.~ ~,~:~.~._.:. .. Resident's or Responsible s Signature '. ..... ' ":'"' ........ :""' · - .... ' ' Date;'?'~' · ~'' ......... -' ' ' ........ _ : : . ~... , Guarantor's Signature ....' ......... ~'~' --'= '~".-. ':,';.~.-'" -, . ' ~':' .~"_.h_" ~''~ '.~. - . . -.- ,',' ' ~:-~: ' ....... '' ,.; ',. - . , : ... , ,,_ . ..,. ~.; ..; ~. ~.. ,,:, ,,:?:~- . ~..:.-.'.~ Revle ed y:' '.. ~ -";i: :~: i:..'...:.. ?" :',;'~' ¢": ~'~" ~. '",'~' ;:. 'i':':' "' '-'~':' -' · ......... ' '"' :,'".'- I m~ss~ons, s Sionature.. · ' .- .... : ~- + r'.: .;'. '.-~,.,,.~.~rvrto~'-'-- :..:. "~/ ~- . -.:.._-.Date.'-'..' -- :' ./' ;...,-: , , : -, :?~:.-~ -. . :..~ ....... : _ -.-7~.- ....., ....,- . -. ! · , ...~:~ ~ ~m t o""m'-'s'rat-r'sSi-'gnature .... :-;, '"" HCR*ManorCare MANORCARE CARLISLE 372 940 WALNUT BOTTOM ROAD CARLISLE, PA 17013 (717)-249-0085 PRIVATE STATEMENT ROOM Strine, Stewart 21084 08/13/01 09/30/01 Cable Rental $5.00 10/31/01 Cable Rental $5.00 11/30/01 Cable Rental $5.00 11/5-11/30/01 Private Portion $905.00 11/30/01 Insurance Premiums -$50.00 12/01/01 Private Portion $905.00 12/31/01 Insurance Premiums -$50.00 01/31/02 Cable Rental $5.00 01/31/02 Private Portion $929.00 01/31/02 Insurance Premiums -$54.00 02/28/02 Cable Rental $5.00 02/28/02 Private Portion $929.00 02/28/02 Insurance Premiums -$54.00 03/31/02 Cable Rental $5.00 03/31/02 Private Portion $929.00 03/31/02 Insurance Premiums -$54.00 04/30/02 Cable Rental $5.00 04/30/02 Private Portion $929.00 04/30/02 Insurance Premiums -$54.00 Payment Due Upon Receipt Amount Due $5,245.00 EXHIBIT