HomeMy WebLinkAbout02-3077PRESBYTERIAN HOMES, INC.,
t/d/b/a GREEN RIDGE VILLAGE,
2-(() S p o-? P-A_ Plaintiffs
VS.
JADE JACOBS,
-PpaZa ell Defendant
?;cc5?lcur pA 1701- Nly
IN THE COURT OF COMMON PLEAS
OF CUMBERLAND COUNTY, PENNA.
NO.: 0-z- 3o7-7 &?,?
CIVIL ACTION - LAW
V PRAECIPE FOR WRIT OF SUMMONS
TO THE PROTHONOTARY:
Please issue a writ of summons in the above-captioned action. Writ of Summons
shall be issued and forwarded to the York County Sheriff, for service upon the Defendant.
Paula J. McDermott, Esquire
Killian & Gephart, LLP
218 Pine St., P.O. Box 886
Harrisburg, PA 17108-0886
(717) 232-1851
Signature
Supreme Court ID No. 46664
Date: June 25, 2002
WRIT OF SUMMONS
TO THE ABOVE NAMED DEFENDANT:
YOU ARE NOTIFIED THAT THE ABOVE-NAMED PLAINTIFF HAS COMMENCED
AN ACTION AGAINST YOU.
a o
Prothonotary
Date: 6??- o?Ud.2 by e .. 4?? r
D putt j
SHERIFF'S RETURN - OUT OF COUNTY
SASE NO: 2002-03077 P
CO COMM
ONWiALCj7MOF P CUMBERLAND
PRESBYTERIAN HOMES INC TDBA GR
VS
JACOBS JADE
Sheriff or Deputy Sheriff who being
R. Thomas Kline he made a diligent search and
sworn according to law, says, that
duly to wit:
and inquiry for the within named DEFENDANT
JACOBS JADE J
in his bailiwick. He therefore
but was unable to locate Her County, Pennsylvania, to
deputized the sheriff of YORK -
serve the within WRIT OF SUMMONS
2002, this office was in receipt o
attached return from YORK
So answers•
Sheriff's Costs: 18.00
Docketing
9.00
Out of county 0.00 Thomas Kline
Surcharge 190.08 Sheriff of Cumberland County
Dep York County 00
127 08
07/22/2002
KILLIAN & GEPHART
Sworn and subscribed to before me
this d.w.C day of llu?
A.D.
Prothonotary
COUNTY OF YORK
OFFICE OF THE SHERIFF S717)77 901L
28 EAST MARKET ST, YORK, PA 17401
SHERIFF SERVICE
PROCESS RECEIPT, and AFFIDAVIT OF RETURN
S>aei - fff
Presbyterian Homes, Inc., t/d/b/a Green Ridge Village fa.
-.7U// civ
Jade Jacobs I Writ of Summons
SERVE 5. NAME OF INDIVIDUAL, COMPANY, CORPORATION, ETC. TO SERVE OR DESCRIPTION OF PROPERTY TO BE LEVIED, ATTACHED, OR SOLD.
W SNESS.T S147EEE
6. ADDRT OR RFD WITH BOX NUMBER, APT NO., CITY, BORIC, TWP., STATE AND ZIP CODE
AT 6 Penza Court, Dillsburg, York County, Pennsylvania 17019-8929
7. INDICATE SERVICE: 0 PERSONAL O PERSON IN CHARGE DEPUTIZE 01ST CLASS MAIL O POSTED D OTHER
NOW une I, SHERIFF OF COW, , do hpyeby deputize th s arc of
or COUNTY to execute th' j'Ilffli Igke return th cording
to law. This deputation being made at the request and risk of the plaintiff.
SHERIFF of ONEIM C U Y
8. SPECIAL INSTRUCTIONS OR OTHER INFORMATION THAT WILL ASSIST IN EXPEDITING SERVICE: Cumberland
OUT OF COUNTY
CUMBERLAND
ADVANCED FEE PAID BY SHERIFF
NOTE ONLY APPLICABLE ON WRIT OF EXECUTION: N.B. WAIVER OF WATCHMAN - Any deputy sheriff levying upon or attaching any property under within writ may leave
same without a watchman, in custody of whomever is found in possession, after notifying person of levy or attachment, without liability on the part of such deputy or the sheriff to any
plaintiff herein for any loss, destruction, or removal of any property before sheriffs sale thereof.
9. TYPE NAME AND ADDRESS of ATTORNEY/ORIGINATOR and SIGNATURE Paul J>5 Bo IcIrt oh8, 10. TELEPHONE NUMBER 11. DATE FILED
Esquire, Killian & Gephart, LL$? 218 Pine Stree, x ,
Harrisburg, PA 17108-0886 ira--¢o ?r• PAkc0p (717) 232-1851 6-26-02
12. SEND NOTICE OF SERVICE COPY TO NAME AND ADDRESS BE : (This area must be comp) d If notice is to be mailed).
Paula J. McDermott, Esquire, Killian & Gdphart, LLP, 218 Pine Street, P.O. Box 886,
171 8-0886
` F
13.1 acknowledge receipt of the writ SIGNATURE OF AUTHORIZED CLERK 14. Date Received 15. ExpirationlHeanng Date
or complaint as indicated above. , AHRENS YCSO -2-02 -26-02
16. HOW SERVED: PERSONAL RESIDENCE POSTED( ) POE ( ) SHERIFF'S OFF ( I OTHER ( ) SEE REMARKS
17. I hereby cersfy and return a NOT FOUND because I am unable to locate the individual, company, corporation, etc, named above. (See remarks below.)
NA AN TR OF DIVID ?LSERVED / LIST ADDRESS HERE IF NOT SHOWN ABOVE (Relationship to Defendant) 19. Date of Service 20. Time of Service
f 2A
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4-3 73
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23. Ado„psts 24. Service Costs 25. N/F 26. Mileage 27. Postage 28. Sub Total 29. Pound 30. Notary Fee 31. Surcharge 32. Total Costs 3 Cost D r Rsund
UUUU 18.00 70.08 88.08 2.00 90.08 19; - nq
34. Foreign County Costs 35. Advance Costs 38. Service Costs 37. Notary Cori. 38. Mileage/Postage/N.F. 39. Total Costs 40. Cost Due or Refund
18 1 1 11 (-)So
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41.AFFIR 44. Signature !r 47
((JJ TARIAL SEAL
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42. day of ME I P%ISHAFFER, Notary Pvc 00 .Signature fYom j, 1
E 48. Dat
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43. pIr a. p" County
d8
ILLIAM M. H
SE
7-18-02
Pro nary °ta °N'c 46. Signature of oreig 49. Date
MY COMMISS EXPIRES - Coun Sheriff
50.1 ACKNOW DGE RECEIPT OF E SHERIFFS RETURN SIGNATURE 51. Date Rece ived
1
Ur AU I HVHI=U IJ UINU All I HUtn I Y ANU I I I Lt
1. WHITE - Issuing Authority 2. PINK -Attorney 3. CANARY - Sheriff's Office 4. BLUE - Sheriff's Office
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PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE,
Plaintiff,
VS.
JADE JACOBS,
Defendant.
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY
. CIVIL ACTION - LAW
: NO. 02:3077 CIVIL
PLAINTIFF'S MOTION TO COMPEL ANSWERS TO DISCOVERY
AND NOW comes Plaintiff Presbyterian Homes, Inc., t/d/b/a Green Ridge Village, by
and through its attorneys, Duane Morris LLP, and in support of this Motion to Compel Answers
to Discovery, avers as follows:
1. Plaintiff served Plaintiff's First Request for Production of Documents and Plaintiff's
First Set of Interrogatories via certified mail on July 2, 2002; the mailing was returned because it
was unclaimed.
2. Plaintiff served Plaintiff's First Request for Production of Documents and Plaintiff's
First Set of Interrogatories via first class mail on or about July 24, 2002.
3. Plaintiff received a copy of a Chapter 13 Plan filed by Barry D. Jacobs and Jade K.
Jacobs, signed and dated July 10, 2002, which was filed with the United States Bankruptcy Court
for the Middle District of Pennsylvania at Case No. 1-02-02330, on August 5, 2002.
4. Plaintiff filed a Proof of Claim Form with the United States Bankruptcy Court for the
Middle District of Pennsylvania in regards to Case No. 1-02-02330 on October 31, 2002.
5. On April 25, 2003, the honorable Bankruptcy Judge Mary D. France issued an Order
dismissing Case No. 1-02-02330.
HBG\114564.1
6. Plaintiff is entitled to discovery responses to enable it to file a complaint in this
action.
7. To the best of the undersigned's knowledge, Defendant is not represented by counsel
in this action; therefore, concurrence of counsel was not sought.
WHEREFORE, Plaintiff respectfully requests this Honorable Court to sign the Order in
the form attached compelling Defendant to answer the Interrogatories and Request for
Production of Documents within ten (10) days of the date of the Court's Order, or suffer
sanctions.
Date: 2 00
Respectfully submitted,
DUANE MORRIS LLP
dl?a ?
Paula J. Mc rmott
I.D. No. 46664
305 North Front Street, 5 h Floor
P.O. Box 1003
Harrisburg, PA 17108-1003
(717) 237-5500
Attorneys for Plaintiff
Presbyterian Homes, Inc., t/d/b/a Green
Ridge Village
HBG\114564.1
CERTIFICATE OF SERVICE
AND NOW, this day of May, 2003, I, Mindy R. Fink, a paralegal with Duane
Morris LLP, hereby state that I, this day, served a true and correct copy of the aforesaid
Plaintiffs Motion to Compel Answers to Discovery via first class mail on:
Ms. Jade Jacobs
6 Penza Court
Dillsburg, PA 17019-8929
indy R. Fink
HBG\114564.1
'Ti
C1? (., .
PRESBYTERIAN HOMES, INC. IN THE COURT OF COMMON PLEAS OF
t/d/b/a GREEN RIDGE VILLAGE, CUMBERLAND COUNTY, PENNSYLVANIA
Plaintiff
vs. CIVIL ACTION - LAW
02-3077 CIVIL
JADE JACOBS,
Defendant
IN RE: MOTION TO COMPEL
ORDER
AND NOW, this Zv ` day of May, 2003, a rule is issued on the defendant to show
cause why the relief requested in the within motion ought not to be granted. This rule returnable
twenty (20) days after service.
BY THE COURT,
POST & SCHELL, P.C.
BY: PAULA J. MCDERMOTT
I.D. #:46664
240 GRANDVIEW AVENUE
CAMP HILL, PA 17011
(717) 731-1970
ML ,b r I EKIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE,
Plaintiff,
V.
JADEJACOBS
Defendant.
ATTORNEYS FOR PLAINTIFF
PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNA.
NO. 02-3077
CIVIL ACTION - LAW
NOTICE TO DEFEND
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 OR CANNOT AF-FORD ONE, GO TO OR TELEPHONE THE
OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, PA 17013
800-990-9108
AVISO
Le ban demandado a usted en la corte. Si usted quiere defen-derse de estas demandas
expuestas en las paginas siguien-tes, usted tiene veinte dias de plazo al partir de la fecha de la
demanda y la notifica-cion. Hace falta ascentar una comparencia escrita o en persona o con un
abogado y entregar a la corte en forma escrita sus defensas o sus objeciones a las demandas en
contra de su persona. Sea avisado que si usted no se defiende, la corte tomara medidas y puede
continuar la demanda en contra suya sin previo aviso o notification. Ademas, la corte puede
decidir a favor del deman-dante y requiere que usted cumpla con todas las provisio-nes de esta
deman-da. Usted puede perder dinero o sus propieda-des u otros derechos importan-tes para
usted.
LLEVE ESTA DEMANDA A UN ABOGADO IMMEDIATA-MENTE, SI NO TIENE
ABOGADO O SI NO TIENE EL DINERO SUFICIENTE; DE PAGAR TAL SERVICIO,
VAYA EN PERSONA O LLAME POR TELEFONO A LA OFICINA CUYA DIRECCION SE
ENCUENTRA ESCRITA ABAJO PARA AVERIGUAR DONDE SE PUEDE CONSEGUIR
ASISTENCIA LEGAL.
Cumberland County Bar Association
2 Liberty Avenue
Carlisle, PA 17013
800-990-9108
POST & SCHELL, P.C.
BY: PAULA J. MCDERMOTT
I.D. #:46664
240 GRANDVIEW AVENUE
CAMP HILL, PA 17011
(717) 731-1970
YKt NB Y I ER1AN HOMES, INC.,
GREEN RIDGE VILLAGE,
Plaintiff,
V.
JADEJACOBS
Defendant.
ATTORNEYS FOR PLAINTIFF
PRESBYTERIAN HOMES, INC., t/d/b/a
GREEN RIDGE VILLAGE
IN THE COURT OF COMMON PLEAS
CUMBERLAND COUNTY, PENNA.
NO. 02-3077
CIVIL ACTION - LAW
COMPLAINT
AND NOW, comes Plaintiff, Presbyterian Homes, Inc., t/d/b/a Green Ridge Village
(hereinafter "PHI"), by and through its attorneys, Post & Schell, P.C., and in support of this
Complaint avers the following:
1. Plaintiff, Presbyterian Homes, Inc. is a Pennsylvania non-profit corporation with
an address of 1217 Slate Hill Road, Camp Hill, PA 17011.
2. Defendant Jade Jacobs is an adult individual with an address of 6 Penza Court,
Dillsburg, York County, PA 17019-8929.
3. Ms. Jacobs' mother, the late Barbara Swartz, was a resident at Presbyterian
Homes' facility at Green Ridge Village, Newville, Cumberland County, until her death.
4. Defendant Jacobs had a Power-of-Attorney for her late mother and was
controlling her mother's funds and affairs until her mother's death.
5. Barbara Swartz entered into a contract with Plaintiff for the provision of services
for which she agreed to pay.
6. Defendant Jade Jacobs, on her mother's behalf, undertook to pay her mother's
bills at Plaintiff's facility and to apply her mother's funds to her mother's care.
7. Defendant Jacobs also undertook an obligation to cooperate in the completion of
Medicaid applications so that Plaintiff's facility could be paid for the services provided.
8. Ms. Jacobs listed income and assets for her mother which she did not apply to her
mother's care, including but not limited to a Highmark investment plan retirement plan, as well
as a 1982 Buick Skylark, a mobile home at One Regency Wood, Middlesex, Carlisle, and Social
Security income.
9. None of the proceeds from any of this income or property was applied to
Plaintiff's charges, nor did Ms. Jacobs cooperate in obtaining Medicaid approval for payment of
her mother's account.
10. A true and correct copy of the Power-of-Attojney of Defendant Jacobs for her
mother is incorporated hereby and attached hereto as Exhibit "A."
11. Plaintiff PHI has been damaged by Defendant's tortious and fraudulent conduct in
an amount in excess of $14,304.01.
12. A true and correct copy of the Admission Agreement of Barbara Swartz is
incorporated hereby and attached hereto as Exhibit "B."
13. A true and correct copy of the account of Barbara Swartz showing a balance due
and owing and the services provided is incorporated hereby and attached hereto as Exhibit "C."
COUNT I - FRAUD AND MISREPRESENTATION
14. The averments of Paragraphs 1-13 are incorporated hereby as if set forth fully and
at length.
-2-
15. Defendant Jacobs fraudulently induced Plaintiff to accept her mother in its facility
and fraudulently concealed or misdirected assets of her mother's to her own personal and private
use in her capacity as Power-of-Attorney.
16. PHI relied upon Ms. Jacobs' representations that she would seek medical
assistance for her mother as a material part of its decision to admit the late Barbara Swartz.
17. Defendant Jacobs, as her mother's power-of-attorney, refused to cooperate in
applying for medical assistance, and medical assistance was never, accordingly, granted to her
mother.
18. As a result of Defendant's fraud, PHI has been damaged in an amount of
$14,304.01.
19. Defendant's fraud was intentional and outrageous, and punitive damages should
be awarded against Plaintiff.
WHEREFORE, Plaintiff PHI respectfully requests this Honorable Court to grant
judgment in favor of Presbyterian Homes, hic. and against Jade Jacobs in the amount of
$14,304.01 together with interest, costs, punitive damages, attorneys' fees, and whatever other
relief the Court may consider just and equitable.
COUNT II - BREACH OF CONTRACT
20. The averments of Paragraphs 1-19 are incorporated hereby as if set forth fully and
at length.
21. Defendant has committed breach of contract and a breach of her fiduciary duty.
As her late mother's power of attorney, Defendant had an obligation to apply her mother's assets
to her mother's care.
22. Defendant repeatedly assured the facility that she would do so.
-3-
23. Defendant further assured the facility she would cooperate in applications for
medical assistance in consideration of the services provided for her mother.
24. These agreements were breached by Defendant.
25. Plaintiff has been damaged by the breach in the amount of $14,304.01.
WHEREFORE, Plaintiff respectfully requests this Honorable Court to grant judgment in
its favor and against Defendant in the amount of $14,304.01, with interest, costs, attorneys' fees,
and whatever other relief the Court may consider just and equitable, which amount is below the
jurisdictional limit for compulsory arbitration.
Date: April 23, 2004
Respectfully submitted,
POST & SCHELL, P.C.
P
PAULA J. VC
CDERMOTT, ESQUIRE
Attorney I.D. # 46664
240 Grandview Avenue
Camp Hill, PA 17011
(717) 731-1970
Attorneys t'or Plaintiff
-4-
VERIFICATION
I, Jeff' (?aol's , a duly authorized representative of
Presbyterian Homes, Inc., t/d/b/a Green Ridge Village, Plaintiff in the foregoing action, hereby
affirm that the facts and matters set forth in the foregoing Complaint are true and correct to the
best of my knowledge, information, and belief. The undersigned understands that the statements
made therein are made subject to the penalties of 18 Pa. C.S. §4904 relating to unworn
falsification to authorities.
PRESBYTERIAN HOMES, INC.
By
Name:
Title: ChjeF E;I' Cict l dFf?ce1`
Date: April 20 , 2004
-5-
PECYC D 0
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Jun 26 02 01:50p P.C Operator
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1-r11
776- 149
DURABLr POSPI!R of ATTORNfEY
QQ farrow ALL PERSONS BY THESE PRESENTS, That I,
6a/ ? G-K(k, Sw?42--, of C? I s (A , r e\
appoint -5aoc- -S?ev(cis of
IIDD 1s (ou-? ,
my true and lawful attorney-in-fact
("Agent"), with full power of substitution for me and in my name
and on my behalf generally to transact all business, and sign,
acknowledge, and deliver all contracts, deeds, and other
instruments needed to effectuate any matter or transaction
pertaining to my affairs, all as effectually, in all respects, as
I could do personally.
."without intending to limit or restrict the foregoing
general powers, my said Agent shall have full authority:
1. To sign checks or otherwise make withdrawals from
any account in my name in any bank, financial institution, or
brokerage firm.
2. To buy and sell securities, commodities, and any
other real or personal property, and to execute on my behalf any
powers of attorney or other instruments needed for that purpose.
3. To endorse notes, checks, drafts, bills of
exchange, and other negotiable instruments and to deposit any
funds to which I am entitled in any of my accounts.
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Jun 26 02 01:50p
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776- 149
4- To borrow money for me and on my behalf on
whatever terms and conditions my Agent deems advisable, to sign
all notes or other documents necessary to effect such loans, and
to mortgage or pledge any of my property as collateral security
therefor.
5. To enter, deposit property in, and withdraw
property from, any safe deposit box in my name.
6. To contract for such services, including but not
limited to, accounting, legal, investment advisory, domestic,
clerical, medical, and nursing services, as may be required in
the conduct of my affairs, the operation of my home, and the care
of my person, and to terminate any such services.
7. To authorize my admission to a medical, nursing,
residential, or similar facility and to enter into agreements for
my care.
8. To consent to and to refuse to consent to medical
and surgical procedures and care.
And to do all lawful acts requisite or proper to effect
the above premises or any matter related to or connected
therewith, and I hereby ratify and confirm all. that my Agent
shall do by virtue of these presents.
All authority herein contained is intended to extend to
my interest in property which I hold jointly or as tenant by the
entireties as well as to property in my name alone.
MAUI b9/1S
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776- 149
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Any individual or corporation may rely on this power of
attorney unless notified in writing that it has been revoked or
that I have died and shall be indemnified and held harmless by me
and my estate against any resulting liability or loss.
THIS POWER OF ATTORNEY shall not be affected by my
subsequent disability or incapacity.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal this ;Z.l day of .4 u9(/J?
rs.djuvv
SIGNED, SEALED AND DELIVERED
in the presence of us:
H a&13 S , -74sEAL)
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COMMONWEALTH OF PENNSYLVANIA
COUNTY OF n(? SS.
art g EC.lr?r?D
776- 949
On the c7 Ilday of Au?usr- a006
before me, a
Notary Public in and for the above State and County, personally
appeared (JpRggrt,q
who in due form of law
acknowledged the foregoing power of attorney to be his/her act
and deed and desired that the same might be recorded as such.
Witness my hand and notarial seal the day and year
aforesaid.
nocaryl lput c, l mmonwee t
Pennsylvania
My commission expires: N)OVfMgc: K, aa03
M ao " Said
PuhCkaw*
My Oo w"M Evpku Nov. 17, 9M
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05/13/2M-l U'3:22 Ili /3 /b /63 HH1 H,Abt 0.i
MRR-01-01 THU 11:34 AN GREL., RIDGE VILLAGE FAX NO.. 180L 45445 P. 01102
PRESBYTLIZIAN HOMES, INC.
t NURSLNG CARE ADMISSION AGREEMENT
1. A`l'rRc)t)UC'rICIN _? ?'"??LI ?? -
This Agrccnhcnt is a contract bemccn the parties listed below setting forth many rights and responsibili-
ties of the nursing, facility and the resident.
Long rcrrn esrc facilities and residents of longterm cart facilities have other rights and responsiblEdes
under Pennsylvania law. All of these rights are not listed below, However, to the extent chat this or any
other agri-centcnt, or nursing facility policy, attempts to waive or limit the legal rights of a resident, such
as attempted waiver or limitation is unenforceable and may give rise to a legal action against the facility.
A so, to the extent th.u rhis Agrcan.cnt conflicts with any current or future provision of law, the law is
cuntrollirig.
Residcars of a facility chat has been teamed to participate in Medicare or Medicaid (i.c. the Pennsylva-
nia Medical Assistance Program) have additional rights under federal law. Thesc rights generally extend
to all resicimrs of cerrifled faciites, whether or not Medicare cr Medicaid is paying for this care.
1. PAR'T'IES
'Ilia pnXlies to his Aggeam°nr ere-
(rt) _ 5?.a ly1 /lh ? &rG_ (hr-rein "the facility"), and
(b)_.?f!%?'! 3?'•'tryy _ (hatin "the resident"; if someone other than the resident is named,
indi are that individual's helarionship to the resident, for example, legal guardian or attorney-in•fect).
The pnrtics to this Ag eetnent recognize that the facility cannot require a legally competent person to
designate an atromey-in-fact or other responsible party as a condition for admission as a Resident.
If A. resident is not a party to this Agreement, the responsible parry is entitled to enforce all rights per-
tainio 1 to residency on behalf of the resident and resident Is entitled to the same rights and privileges as
recorded to fully responsible residents who sign the Admission Agreement.
3. WI)fCA12ENL TEDICAID CER'YWICATTON
'Ilia facility is certified to participate in the Medicare and Medicaid program. Provider participation in
the Medicare and/or Medicaid program is subject to termination by the facility or by the responsible
goveininental enrity.
4. ClIARIJ S
n. Covered services:
Beginning on the facility will adtrtit &AVA Q. &k6-6L , the resident.
herein. Unlcss and until the resident is eligible to have his or her care paid for by Medicare or
Medicaid, the facility will chargo the per diem rate in Attachment A for the provision of Iona
term cue services. This charge cover all room and board, items, equipment and services rca-
sonably relatcd to the cave and rrcatment of the resident Payment is due on the lj?
tech; ?tc?/„!/
day of the month. Charges in addition to room and board) arc included in Attachment A.
Than will be no char,^c for any service, equipment or item which is not actually provided to the
resident.
b. Changes in charges
Thu facility ro.ty am<tnd the charges set forth in the preceding section (4(a)) upon thirty (30) days
written intl/or an oral notice to the resident, legal represcntativc (if one exists) and responsible
p:u'ty (if ortc,cxists).
At 05/72
05/13/2002 09:22 7177375763 PHI
PAGE 04
W-01-01 THU 11:32 AM GREt,, RIDGE VILLAGE FAX NO. 16K, ,5445 F. 01/02
If the resident is discharged prior to Lite end of the montti, the facility will provide a pre-rata refund
of any prdpayment for covered services within 30 days of the date of discharge. ,
dl. Milling IVI(dicaro
Payment for residcnts who art: Medicare enrollees is not due unless and until Medicare has
determined that thcre is no coverage. The facility hereby acknowledges its legal resFonsibi!ity to
submit any claitu for payment to the Medicare program if required to do so by or on :xhalf of the
resident,
c. Uillin; i?4edic:aid :3esidtnls
Payment unounts for residents who are entitled to Medicaid arc determined by the Pn. nsylvania
Depannient of Public Welfare. Any payment made to a Medicaid certified facility for die cost of ears
far a private pay resident who is later found to be eligible for Medical Assistance wiL ba refunded
within five (5) drays of notification of resident eligibility." he parties hereto recognize that itis illegal
for a Medicaid certified facility to charge, solicit, accept orreceive additional monies b,-vond what
the Medicaid program detmmmes is due, as a condition for admitting, expediting the 2, ission of,
or rtaauting a resident under Medicaid.
Thc parries recognize that a Medicaid certified facility may charge foriterns, equipme :: or services
not reimbursable under the Medicaid pro.-rim, if the provision of such item, equtprre n. or service
and the charge therefore is disclosed and agreed to in advance, pursuant to law. Mcdie,l recipients
who tun uncertain whethcran item or service is not reimbursable tinder the Medicaid prog sm should
contna the Deparancat of Public Welfhrc, Long Term Care t_litnt Services at (717) iii Z-ZS00-
f. Obtaining Private Payment and Public Benefits
Th s facility will assist the resident and others acrina on behalf of the resident in appl- -g for and
obtaining, private insurance and public benefits to cover the cost of the resident's care.
'ncc residcnc rtgrecs to cooperatu to the best of his or her ability with any such applic_:=
g, Werfe•rcuce
The panics acknowicd;e that a Medicaid certified facility may not Muire, in writing or orally, a
promise that a resident will remain in private pay status or refrain from applying for :YL-aeaid for
it specified period of time.
Ir. hfnnucial Guaruntor
The parties acknowledge that under Pennsylvania law, this Agreement standing alone is insuffi-
cient to legally bind any individual as financial guarantor for charges owed hereunder. Any other
person signing this agreaincnt is only obligated to make:payment from the resident's F`.-ds and
only to the extent dear those fiends are available to such signing person. Therefore, if a r_?.ra !tor
ayttxntent exists, it is attached hereto as Attachment B.
S. PROTYCTION OF R ESIDENP'S PROPER'fy
The facility will rake reasonable steps to prevent the theft or loss of the resident's property.
The resident is not required to deposit personal funds (including„ but not limited to Social Scc=..y and
pension checks) with the facility. If the resident wishes, however., die facility will hold, safeguard and
account for any personal funds deposited with the facility, in accordance with state and federal raw.
The parties acknowictigc that any resident funds held by the facility are subject to various provisions of
state antVor federal law goveming access to the funds, mandatory posting of interest and ropor'_^g on
the status of said funds.
11ir. procedure fur filin, elairns for property of the resident which is lost or stolen is set fnali E-
Atrachmcm C.
05/13/2bbL by: 11 Ill/d lb lb3 h'Hl Hint ??
MAR-01-01 THU 1134 AM GREL,. RIDGE VILLAGE FAX NO. 18M .5445 P. 02/02
ti. DLSCIIAItGF. WZ TUANSFf R UhT[Ir Rl?SIDI:NT f RU1I THE FACILITY
a. Reasons fur'1'rnnsfm• or Uischorec
The facility will not discharge or transfer the resident from the facility except for medical reasons,
for his or lief welfare or that of other residents, for nonpayment for his or her stay after the facility
has mode reasonable effuns to eullccr the debt, or if the facility ceases to operate,
b. i`lutica of'fr:rnsfcr ur Disch:u gc
In the event that adisch r,eortransferisnecessary and, except in an emergency, the facility willgive
30 days advance wiWea notice to the resident, to any legal representative, to the responsible party
(if one exists) and to others required by law to receive this notice.? ne written notice will set forth
the reason for the transferor discharge, the effective date of the transferor discharge and the location
to which the resident will be transferred or discharged.
T hn l notice will also set forth arty appeal rights that the resident has under law and additional
infomnation required by stare and/or fr-dcral law. In the event of an emergency, the facility will
give the residert as much notice as is possible under the: circumstances.
e. Facility ltespondbility for Transfer or Discharge
In the event that a transfer or discharge is necessary, the facility will provide sufficient prepara-
doo to nssure that the transfer or discharge is safe and orderly. The facility is responsible for
transferring the resident to an appropriate level of care.
d. I•lolding the Rrddent's Fled Upon Transfer
1. HOSPITAr.IZATIUN. In the event that the resident is transferred to a hospital,
the facility will hold the resident's bud for up to fifteen days, If the resident is
Medical Assistance elieibla and the facility is Medical Assistance certified.
If the resident is entitled w Medicaid benefits far the period, and the facility is
certified under the Medicaid program, the facility will accept Medicaid bed hold
payments as payment in full. If the resident is not Medical Assistance eligible,
the facility will accept the normal per diem listed in Attachment A.
2. THERAPEUTIC LEAVIi. In the event the resWent is absent from the facility on
tilers,pcudc lenve, the facility will hold the bed upon payment of the facility's
Medical Assistance interim per diem rate, or, if Lhe facility is not certified under
Mediml Assistance, upon payment of the per diem rate listed in Attachment A.
If the residential entitled to Medicaid benefits during therapeutic leave,
the facility will accept Medicaid bed hold payments (limited to 15 days per
calendar year for skilled care residents and 30 days per calendar year for
intermediate care residents) as payment in full. !"be resident's calendar year
begins on the day of lsr therapeutic leave.
3. NPX I' AVAMABLE BED. In the event the resident and others acting on behalf of the
resident choose not to pay to reserve a led as set forth in paragraphs (1) and (2),
die resident is nevertheless endded to the next available bed when he/she is ready
to rerun to the facility.
7. TItANSP1,MS WI'1'IiP4 7111, FAcil-r "k'
The n.sident will not be transfL=ijd within the facility except for medical reasons, for his or her welfare
or that of other residents, or with the voluntary consent of the resident or his or her legal representative,
In the event of a transfer hereunder, except in an emergency, the facility will give prompt advance notice
to file rosidcnt, io the responsible patty (if one exists), to any legal representative and to any fanilly
member who is known to the facility. The notice will start the reason for the transfer, the effective date
and the location to which the tusideut will he moved.
In the event that a iranyfcr widtin (Ili; facility is uecc;;ary, the facility will provide sufficient pieparatiou
to assum that the ransfcr :s safe and orderly.
05/13/2002 09:22 7177376763 PHI PAGE 06
MAR-01-01 THU 11!33 AM GREL„ RIDGE VILLAGE FAX NO. 1800, ,5445 P. 02/02
1?• W:,Jt111'1'11 JPIV„,-
The parties recognize Ulat federal and state law guarantee the resident other rights w=ith are not sot forth
fully to this auccmcnt. The facility agrccs to uphold all of the rights of the resident under federal and
SL,itc lrw. Resident rights art included in Attachment D.
9. VISI'VING 1101AIS
Visiting hour: are opurt, however the facility requests that late arrivals (after 9:00 p.=:-) be cleared with
tttc facility adminisnation in advance.
It 1:FSOLVING I SIUENT AND FAWLY CONCERNS
'11e parries recognize the right of the resident to recommend changes In the facility and the responsi-
biliry of the facility TO respond to the suggestions of the residents. Atmehment E her_m sets forth the
rnann„r by which n resident or others acting, on behalf of the resident can suggest changes to die facility,
the steps which the facility will take to encourage and assist residents in voicing then concerns, and the
method by which the facility will review and respond to the suggestions of residents =d others acting
on their behalf.
T7tc Pardes rxu;pizc that Tito Pennsylvania Deparuncar of Aging has assigned an Cmbudsman to each
nttrsinafvcili ty in the state. The Ombudsman way assist theresidentor others acting on behalf of the resident
in resnlving disputes with the facility.
i1. REGIJLATORY AcmNCTF.ae
The parties rceognize tint the facility is licensed by the Department of Health and is rn, Iared by the
Pennsylvania 1),:parmient of Welfare and the Health Care Financing Administration, of the U.S. Depart-
ment of Healtli and Iluraart Services. Both parties rroognize thatingulatory changes =ay alter the
condition: of this agreement.
12 CIVIL ]OUGHTS COM•PLIANC9
Pcesbytetitui Iiomes' facIlkies are open to all in'need of our services, and arc not res-'sled to
Pwsbyterinns. Also, hi accordance with the Federal Civil Rights Aix and the Penn: '.Vania Flur:an.
Relations Act, P.L.. 744:
This facility has agreed to comply wide the provision of d1e Federal C1vi1 Rights Act of 19154,
and the Pennsylvania Human Relations Act, and all requiromeats proposed ;---want thereto,
to tha end that no persons shall on die grounds of race, color, religious creed. national origin,
oncesoy, age, sex, hanricap or disability should be excluded from pardcipat=g in, be denied
baneGts of, or odicrwise be subject to discrimination.in the provision of any ,.:re or service.
The non-discriminatory policy of the Institution applies to residents, physicians, and all
crrtployces. Under no circumstances will the application of this policy result ';-n the segre.gation
of buildings, wings, floors, and roonis for reasons of race, color, religious c::ed, national origin,
nncesi y, age. sex, handicap, or disability.
13. SIGNATURYS
'A.titain•tjataa-
'1`-' ?1 y r? (J r
Resident or Authont Rcuresentativc:
Witness (if the resident signs by a mark
or directs anode cr)
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SWAIM HEALTH CENTER
210 BIG SPRING ROAD
NEWVILLE PA 17241-9486
A"OUNTS RECEIVABLE STATEMENT
Statement Date: 0413012002
Balance Due: 14,304,01
BARBARA SWARTZ
c/o JADE JACOBS
6 PENZA CT
DILLSBURG PA 17019
Account Number: 60938
Balance Forward: 14,304.01
SWAIM HEALTH CENTER: BARBARA SWARTZ 60938
CERTIFICATE OF SERVICE
I, Dena J. Stump, an employee of the law firm of Post & Schell, P.C., do hereby certify
that on the date set forth below, I did serve a true and correct copy of the foregoing Complaint
upon the following person at the following address indicated below by sending same in the
United States mail, first-class, postage prepaid:
VIA CERTIFIED MAIL
Jade Jacobs
6 Penza Court
Dillsburg, PA 17019
POST & SCHELL, P.C.
Dena J. p, Secretary
Date: Apriro, 2004
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Curtis R. Long
Prothonotary
office of the Protbonotarp
Cuntberlanb Countp
Renee K. Simpson
Deputy Prothonotary
John E. Slike
Solicitor
6a2 -36~I7CIVIL TERM
ORDER OF TERMINATION OF COURT CASES
AND NOW THIS 5TH DAY OF NOVEMBER 2007 AFTER MAILING NOTICE OF
INTENTION TO PROCEED AND RECEIVING NO RESPONSE - THE ABOVE
CASE IS HEREBY TERMINATED WITH PREJUDICE IN ACCORDANCE WITH PA
R C P 230.2.
BY THE COURT,
CURTIS R. LONG
PROTHONOTARY
One Courthouse Square • Carlisle, Pennsylvania 17013 • (717) 240-6195 • Fax (717) 240-6573