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Home My WebLink About95-02906 .~ .0. .~ € ....~ ':iF .-.........:. '-:"::," 'j ~: tf.'.-:'" ,,} .. . .~ \0 '0- ..'.... "'. cO \ \,~, \ ) / ./ . . .... ....;;t, .:.~ ;C:'.','.:r .',-' .-.", "'" #- p~ ~. .. "" f .. ; lii ' ;',' _,L, .,i-f .'f, ;,;:,'; . "".,-, .,.,.....-."-...-.....c....c ..... .1. " < . ..ti~~1 nA11IEIl '~n'" ,.", ~,22a,' .',,~..r.,'.~.,..,,;",}'<,"".. A . ",'!Ii , 'm ". "5<~1 . . .'S~-" _ .,"'0 ....."....T.....1i!.; JlAl( n7/16"'.1~ '. " . ", -',,' -: .....'. :";''0..$ ... . . UNITED CHURCH OF CHRIST HOMES, INC. t/a/d/b THORNWALD HOME, Plaintiff VS. IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION NO. (i~' I 'Ie '. (i""I' 1.,.- EUGENE A. PALM, AN INCAPACITATED : PERSON THROUGH HIS WIFE AND GUARDIAN, JOAN K. PALM, AND JOAN K. PALM, INDIVIDUALLY Defendants 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 prompt 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 AFFORD ONE, GO TO OR TELEPHONE THE OFFICE SET FORTH BELOW TO FIND OUT WHERE YOU CAN GET LEGAL HELP. Court Administrator Cumberland County Courthouse 4th Floor 1 Courthouse Square Carlisle, PA 17013-3387 717/240-6200 rltm.com 02 5/18/95 1 UNITED CHURCH OF CHRIST HOMES, INC. t/a/d/b THORNWALD HOME, Plaint i ff IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY, PENNSYLVANIA CIVIL DIVISION VS. NO 'f', .)'1((.. e({:rt .r:........... . EUGENE A. PALM, AN INCAPACITATED , PERSON THROUGH IllS WIFE AND GUARDIAN, JOAN K. PALM, AND JOAN K. PALM, INDIVIDUALLY Defendants TO, THE PROTHONOTARY OF CUMBERLAND COUNTY, Please enter the appearance of FEATHER AND FEATHER, P,C. 22 West Main Street, Annville, PA 17003 as attorneys for the plaintiff in the above- captioned case. FEATHER AND FEATHER, P.C. Date f) \L\J\ ~ -; , ' '-- ) ( \ ~\\ By? . l' l~i~r JO~ ~~ FEATHER, .1 10 ~{<2P6 \ 22 West Main Stre Annville, PA 17003 717/867-1200 Attorneys for Plaintiff Palm.tom 02 ~/'e/95 2 4. The defendant, resides at R.D. 17047. 5. The defendant, Eugene A. Palm, and the defendant, Joan K. Palm, are husband and wife, and were married at all times relevant to this complaint. 6. On November 14, 1994, the Court of Common Pleas of Perry County, pA, Orphans' Court Division, at No. 1'-324, adjudicated defendant, Eugene A. Palm, an incapacitated person as that term is defined by the Pennsylvania Probate, Estates and Fiduciary Code and appointed Joan K. Palm, his wife, as his guardian under the pEF code. 7. On May 31, 1994, the defendant, Eugene A. Palm, was admitted to Thornwald Home for care following hospital treatment for head and other injuries suffered in an accident. 8. At the time of the admission of the defendant, Eugene A. Palm, to Thornwald Home, the defendant, Joan K. Palm, signed a Nursing Home Admission Agreement on behalf of her husband who was incapable of signing said Admission Agreement because of his injuries. A copy of that Nursing Home Admission Agreement is attached hereto and identified as Exhibit A. 9. On the Admission Agreement the defendant, Joan K. Palm, acknowledged herself as the responsible party for the bills that may be incurred on behalf of defendant, Eugene A. Palm, and directed that all statements for nursing care sel-vices and other services provided by Thornwald lIome to defendant, Eugene A. Joan K. Palm, is an adult Ill, Box 328E, Loysville, individual, who Perry County, Ph Palm.cem 02 5/18/95 4 Palm, should be sent to the defendant, Joan K. Palm. 10. From the time of the admission of defendant, Eugene A. Palm, until the present, all statements for services provided by the plaintiff to the defendant, Eugene A. Palm, were sent to the defendant, Joan K. Palm. The defendant, Joan K. Palm, did not return any of the statements nor did she notify the plaintiff that she was not responsible for the debts of hel- husband, Eugene A. Palm. In fact, the defendant, Joan K. Palm, has made numerous representations to the plaintiff that the defendant, Joan K. Palm, would pay the amounts due to the plaintiff or arrange for those payments to be made. 11. Since June, 1994, the plaintiff has sent monthly demands for payment for the services provided to the defendant, Eugene A. Palm, to the defendant, Joan K. Palm. 12. The services rendered to the defendant, Eugene A. Palm, by the plaintiff were necessary for his health and welfare. 13. The plaintiff has made demand upon the defendant, Joan K. Palm, to pay for the services rendered to defendant, Eugene A. Palm, by the plaintiff between May 30,1994 and May 31, 1995 which were not paid by any other source, but the defendants have failed or refused to make payment on this account, except for a payment of $3,547.00 on or about 8/3/94. 14. The fees charged by the plaintiff for the services that were provided to the defendant, Eugene A. Palm, were all fail" and reasonable and those cllstomarily chal-ged for the services provided. A copy of the statements fOl" thoBe Bel:vi ces, logel hel" P.lm.com 02 \/18/9\ 5 with the current balance in the amount of $38,359.45 is attached hereto and identified as Exhibit B. 15. The plaintiff is entitled to its reasonable attorney's fee related to the collection of this account pursuant to Paragraph 2.8 of the Nursing Home Admission Agl-eement, Exhibit A. COUNT I UNITED CHURCH OF CHRIST HOMES. INC. va. EUGENE A. PALM BY HIS GUARDIAN, JOAN K. PALM - CONTRACT 16. Paragraphs 1 through 15 are incorporated herein by reference. 17. The defendant, Eugene A. Palm, received all of the services from the plaintiff described in the foregoing paragraphs and agreed to pay for those services under the terms of the Admission Agreement executed in his behalf by Joan K. Palm as his wife and as his guardian and has failed or refused to pay for those services. WHEREFORE, the plaint if f, United Church of Christ Homes. Inc. demands judgment against the defendant, Eugene A. Palm, in the amount of $38,359.45 together with costs, intere[lts and reasonable attorney's fees. COUNT II UNITED CHURCH OF CHRIST HOMES. INC. VS. EUGENE A. PALM BY HIS GUARDIAN. JOAN K. PALM - QUANTUM MERUIT 18. Paragraphs 1 tlll-ough 17 al-e incorporated herein by reference. 19. The services deIJcribed in this Complaint as being received by defendant, Eugene A. Palm, were those which were requested on his behalf by the defendant, Joan K. Palm. They were necessary r.lm.com vz S/18/9S b for his health and welfare and if he does not pay for them in the amounts described herein, he will be unjustly enriched at the expense of the plaintiff. WHEREFORE, plaintiff demands judgment against the defendant, Eugene A. Palm, in the amount of $38,359.45 together with costs, interests and reasonable attorney's fees. COUNT II I UNITED CHURCH OF CHRIST HOMES. INC. VS. JOAN K. PALM 20. 1 through 19 are incorporated herein by reference. 21. The defendant, Joan K. Palm, is the responsible party for the services provided to the defendant, Eugene A. Palm, under the terms of the Nursing Home Admission Agreement described herein and by her conduct of accepting responsibility for the costs of those services. 22. The defendant, Joan K. Palm, is the spouse of the defendant, Eugene A. Palm, and is legally responsible for the costs of providing necessary services to her husband by the plaintiff at its facility known as Thornwald Home. WHEREFORE, the plaintiff demands judgment against the defendant, Joan K. Palm, in the amount of $38,359.45 plus costs, interests and reasonable attorney's fees. Date: j " ( \,\ ~ Respectfully submitted, FEATHE~ FEATHER, P.C. r' ~I) \ By: ,\, (.)i^\\. JOliN E. FEArfI'R, JR., Esq. 5756 \ 2 st Main Street Annville, PA 17003 (717) 867-1200 Attorneys for Plaintiff Palm.com D2 5118195 7 rnORNWALD HOME NURSING HOME ADMISSION AGREEMENT TIns AGREEMENT made this 27th dayof Mill' ,1994 , belween Thornwald Home, located al 442 Walnul Bottom Road, Carlisle, Pennsylvania, (hereinafter called HOME) and Eugene A. Palm , of Loysvllle, Pennaylvania , (hereinafter called RESIDENT) fortheadmlsslon of RESIDENTlo HOME,and Joan K. Palm , of Loysvllle, Pennsylvania ,(RESIDENT's legal representative or Individual who has laWful access to RESIDENrs Income or financial resources available to pay for HOME's services, hereinafter called RESPONSIBLE PARTY) shall commence on May 31, 1994 RESIDENT, having applied for admission, and RESPONSIBLE PARlY, II any, affirm that the Information provided In HOME's Application for Admission Is true and correct, and acknowledge that the submission of any false Information may constitute grounds for termlnaUng this agreement. Therefore, HOME, RESIDENT, and RESPONSIBLE PARTY, If any, agree to the following terms and conditions: 1. PROVISION OF SERVICES 1.1 Basic Services Provided by HOME HOME agrees to provide basic services to RESIDENT which include room and board, routine nursing services, social services, dietary services, housekeeping and room/bed maintenance, activities, bedding,linen, and such personal services as may be determined by HOME to be legaliy and reasonably required for the health, safety, welfare, good grooming, and weli-belng of RESIDENT. 1,2 Supplemental Services and Supplies Provided by Home Home agrees to provide supplemental services and supplies as shown on the HOME's Schedule of Charges as may be requested by RESIDENT or as may be determined by HOME to be legally and reasonably required for the health, safety, welfare, good grooming, and well-being of RESIDENT. 1.3 Services of Physicians Medications, treatments, therapy, diet and other services are provided under the direction of RESIDENT'S attending physician. HOME agrees to permit RESIDENT to choose his or her own physician. HOME reserves the right to appoint a physician for RESIDENT if RESIDENT or RESPONSIBLE PARTY fails to do so, or If physician selected by RESIDENT or RESPONSIBLE PARlY fails to comply with HOME's policies, procedures or regulations. I:.XHIBIT .1l_ PAGE --L- 1.4 Services of Other Providers HOME agrees to permit residenlto choose othor providers of non-facility sorvices conditioned by the provider's cOlllplianco with HOME's policies and procedures. 2. FEES AND CHARGES 2.1 Obligation 01 RESIDENT or RESPONSIBLE PARn' RESIDENT, or RESPONSIBLE PARn' solely from RESIDENT's financial resources, shall be responsible for the payment of all charges assessed by HOME for the services and supplies HOME provides to RESIDENT. Non-payment of charges may result in HOME's termination of this agreement after notification to RESIDENT or RESPONSIBLE PARn'. 2.2 Schedule 01 Charges RESIDENT or RESPONSIBLE PARn' acknowledges receipt of HOME's Schedule 01 Charges for basic and supplemental services, which are considered part of this agreement. HOME retains the unilateral right to raise, lower, or modify the Schedule of Charges, and such change shall be effective no sooner than thirty (30) days after RESIDENT or RESPONSIBLE PARn' receives written notice thereof. II RESIDENT requests items or services not included on the schedule of charges, HOME will advise resident of the cost, if any, of such item or service. 2.3 Advance Payment 01 Basic Service Charges RESIDENT, or RESPONSIBLE PARn' solely from RESIDENT's financial resources, agrees to pay basic service charges in advance. The first payment shall be In the aggregate amount of the basic service charges for each day starting with the date this Agreement commences to the end of the month. Thereafter, advance charges lor basic services shall be due on the twenty-fifth (25th) day of the month In wrich services are being provided. Advance payment of basic service charges is not required if RESIDENT or RESPONSIBLE PARTY has reasonable expectation that services will be covered by Medicare or Medicaid. II HOME does not concur with RESIDENT or RESPONSIBLE PARTY's expectation of Medicare coverage, RESIDENT or RESPONSIBLE PARTY must request in writing that a demand bill be submitted to the Medicare intermediary. When such wrillen request is made, no advance payment will be required while the Medicare intermediary reviews the request. II RESIDENT or RESPONSIBLE PARTY believes that RESIDENT is eligible for Medicaid benefits payable to HOME and submits a completed application for Medicaid benefits, no advance payment will be required while the application is being reviewed. 2 EXHIBIT .Li.- PAGE ~ 2.4 Payment of Medicare Deductible and Co-Insurance Amounts Except when RESIDENT is eligible for Medicaid or when Medicare deductible and co-Insurance amounts are covered by an insurance with which HOME has a participating provider relationship, RESIDENT, or RESPONSIBLE PARlY solely from RESIDENT's financial resources, ogrees to poy Medicare deductibles and co- insurance amounts. Payment of deductible and co-Insurance amounts Is due on the twenty-fifth (25th) day of each month following the month In which the services or supplies were provided. 2.5 Payment of Medicaid Income Based Co-payments RESIDENT, or RESPONSIBLE PARlY solely from RESIDENT's financial resources, agrees to pay Medicaid income based co-payments in the amount determined by the Medicaid program. Payment of Medicaid co-payment amounts is due on the twenty-fifth (25th) day of each month following the month in which services were provided. 2.6 Payment of Supplemental Services and Supplies Charges RESIDENT, or RESPONSIBLE PARlY solely from RESIDENT's financial resources, agrees to pay supplemental charges for services and supplies not included in the basic service charge. Payment for supplemental charges is due on the twenty-fifth (25th) day of each month following the month in which the services or supplies were provided. 2.7 Payment of Services by Physicians and Other Providers Payment of services provided by Physicians is the responsibility of RESIDENT. Except where services of other providers are payable to the home by Medicare or Medicaid under the terms of HOME's provider agreements, RESIDENT is responsible for payment of services by other providers. 2.8 Late Charges and Costs of Collection RESIDENT, or RESPONSIBLE PARlY agrees to pay late charges calculated on the basis of one and one-quarter percent (1.25%) per month on charges for services and supplies that are at least thirty (30) days past due. RESIDENT, or RESPONSIBLE PARlY agrees to pay reasonable costs of collecting past due accounts, Including attorneys fees. 2.9 Refunds of Overpayments Overpayments will be refunded within thirty (30) days following the last day of the month in which RESIDENT is discharged. 3. MEDICARE AND MEDICAID 3.1 Participation In Medicare and Medicaid HOME participates In both the Medicare and Medicaid Programs. HOME agrees 3 [XHI13\T ~PAG[ ~ to provide services of the samu quality and typo of cm 0 rouardless of source of payment. RESIDENT and RESPONSIBLE PAHl V, if any, oclmowledgo \I,at no representation, statement, or claim has been made by anyone connected with HOME that services to IlESIDENl aro or will be covered under Medicare or Medicaid. HOME makes no guarantoe that services will be covered under either program. RESIDENT or RESPONSI13LE PAIHY reloases HOME, Its agents and employees from any liability or responsibility in connoction with IlESIDENT's potential claim for cover ago under the Medicare, Medicaid, or any other governmental assistance program 3.2 Acceptance of Medicare and Medicaid Rates In the event RESIDENT is determined eligible for benefits undm tho Medicare and/or Medicaid program and is entitied under one or both of these programs to have payment made for all 01 the items ond services provided by HOME, HOME agrees to accept the payment from these programs, plus any related deductible, coinsurance and copayment amounts owed by IlESIDENl, as payment in full for the items and services covered ttlereunder. 3.3 Application for Benefits RESIDENT shall apply promptiy for eligibility and benefits under the Medicare and/or Medicaid program as SOOI1 as RESIDENT appears to meet said program's eligibility requirements. II nESIDENT fails to apply promptly, HOME Is authorized in Its sole discretion to prepare 011 necessary forms and documents from information provided by RESIDENT or RESPONSII3LE PARTY for RESIDENT or RESPONSIBLE PARTY's signature, which nESIDENT or RESPONSIBLE PARTY shall not withhold unreasonably. HOME will submit such forms Bnd documents to the appropriate state and/or federal agencies for a determination of RESIDENT's eligibility and benefits under the Medicare and/or Medicaid program. 3.4 Non-Covered Services RESIDENT, or RESPONSI13LE PARTY solely from RESIDENT's financial resources, agrees to pay charges for non-covered items and services Payment for supplemental charges Is due on the twenty-flllll (25th) day of each month following the month in which tile services or supplies were provided. 4, BED RESERVE PROVISIONS 4.1 Private Pay Re61dents In tile event RESIDENT, willie not eligible for benefits payable to HOME under tho Medicaid program, is discharged from HOME for the purpose of being admitted to a Ilospital or for tile purpose 01 therapeutic leave, HOME sl\all reserve RESIDENT's bed until such timo as IlESIDENl rnturns to HOME or nESIDENT or RESPONSI13LE PAI11V notifies HOME in writlf\\] of IlESlDEtH or RFBPONSIOLE 4 /) l~t'I' " I" J. ........-.-- PARTY's intention to terminate this Agreement. HOME sllall cllarglJ and RESIDENT shall pay HOME's current daily private rate for eacll day a bed is reserved for RESIDENT until RESIDENT either returns to HOME or terminates tllis Agreement. 4.2 Medicaid Residents In the event RESIDENT, while eligible for benefits payable to HOME under tile Medicaid program, Is discllarged from HOME for the purpose of being admitted to a hospital, HOME shall reserve a bed for RESIDENT for up to fifteen (15) days per hospital stay. After such time, HOME shall not be obligated to reserve a bed for RESIDENT, but will readmit RESIDENT to the first available semi-private bed upon discllarge from the hospital. In the event RESIDENT, while eligible for benefits payable to HOME under the Medicaid program, is discharged from HOME for the purpose of therapeutic leave, HOME shall reserve RESIDENT's bed for up to fifteen (15) days per year if RESIDENT is receiving skilled care or up to thirty (30) days per year if RESIDENT is receiving intermediate care. After such time, HOME shall continue to reserve RESIDENT's bed If, before the expiration of said period, RESIDENT or RESPONSIBLE PARTY notifies HOME in writing of RESIDENT's intention to return to HOME and RESIDENT's agreement to pay HOME its then current rate for each additional day RESIDENT's bed is reserved. 4.3 Medicare Residents Medicare does not provide benefits payable to HOME for reserving a bed. In the event RESIDENT is eligible for benefits payable to HOME under the Medicaid program, bed reserve provisions will be in accordance with those described above for Medicaid residents. In the event RESIDENT is not eligible for benefits payable to HOME under the Medicaid program, bed reserve provisions will be in accordance with those described above for Private Pay residents. 5, PERSONAL AND OTHER PROPERTY 5,1 RESIDENT Responsibility RESIDENT or RESPONSIBLE PARTY agree to provide such personal clothing and effects as needed or desired by RESIDENT, subject to space limitations In HOME. RESIDENT Is permitted to retain personal possessions that meet safety criteria. HOME may place restrictions on items that infringe upon the rights of others or are contraindicated by RESIDENT's physician as documented in the medical record by RESIDENT's physician. RESIDENT is responsible for maintaining insurance on any personal property or valuables kept at HOME. RESIDENT or RESPONSIBLE PARTY accept sole risk 5 CXIHI3IT .LPAGE ~ and liability for personal property or valuables kept atl1ome. 5.2 HOME Responsibility HOME shall provide RESIDENT with a locked space if requested by RESIDENT. Use of said locked space, and the placement or storage of any Items therein, is recognized as being at the sole risk and liability of RESIDENT or RESPONSIBLE PARTY, and no liability or responsibility whatever with respect to any such items is assumed by HOME. HOME accepts no liability to replace or be responsible for stolen, damaged, lost or misplaced personal property or valuables. HOME strongly recommends that no Jewelry or other valuables be brought to or maintained at HOME. 6. RESIDENT'S PERSONAL FINANCES 6.1 RESIDENT Funds Management RESIDENT Is encouraged to manage his or her own personal financial affairs. HOME will manage RESIDENT's personal financial affairs only when RESIDENT or RESPONSIBLE PARTY designates the transfer of such responsibility In writing. RESIDENT funds managed by HOME will not be commingled with HOME funds. if funds managed for RESIDENT are in excess of $50.00, the amount in excess of $50.00, or, at HOME's option, all funds being held for RESIDENT, will be held in an interest bearing account at a local financial institution insured by the Federal Deposit Insurance Corporation or the Federal Savings and Loan Insurance Corporation. 6.2 RESIDENT's Access to Funds if assistance with financial management is provided, HOME agrees to issue up to $50.00 in cash to RESIDENT upon request during normal business hours, provided that RESIDENT's account balance equals or exceeds the amount requested. Withdrawal of amounts over $50.00 will require reasonable advance notice. 6.3 RESIDENT's Personal Needs Allowance RESIDENT Is permitted to retain a portion of RESIDENT's Income as a personal needs allowance, in an amount determined by the Medicaid Program. RESIDENT Is not required to use any portion of RESIDENT's personal needs allowance for basic or supplemental charges, nor will HOME Impose a charge against RESIDENT's personal funds for services paid for by Medicare or Medicaid. 6.4 HOME Accounting if HOME provides assistance willl financial management to RESIDENT, HOME shall maintain n separate, current individual record of financial transactions for RESIDENT and shall giJe I~ESIDENT or RESPONSIBLE PARTY a quarterly 6 EXHI81T ~ PAGE .L.. accounting of transactions made on RESIDENT's bel13l1. Upon roqucst, RESIDENT or RESPONSIBLE PARTY shall be allowed to roview RESIDENT's financial record during normal working hours. Deposits and expenditures shall be documented with written receipts. Disbursement of funds to RESIDENT or RESPONSIOLE PAR'Tl' shall be documented and RESIDENT or RESPONSIBLE PARl1' shall acknowledge IIle receipt of funds in writing. Accounts sholl clearly renect deposits, receipt of funds, disbursal of funds and the current balance. 6.5 Medicaid and SSI Resource Umltatlons Notification If RESIDENT is eligible for Medicaid, HOME will notify RESIDENT or RESPONSIBLE PARl1' when the account balance accumulates to a point that is $200 IllSS than the Medicaid and or SSI resource limitation that RESIDENT may lose his or her Medicaid or SSI eligibility if the resource limit is exceeded. 6.6 RESIDENT Funds Procedure Following Termination of Service by 1i0ME In the event of termination of service by HOME after thirty (30) days written notice, HOME will provide RESIDENT or RESPONSIBLE PARl1' with an itemized written account of RESIDENT's funds and immediate payment of any balance remaining in RESIDENT's account with HOME. 6.7 RESIDENT Funds Procedure Following Termination of Service by RESIDENT If RESIDENT chooses to leave HOME after giving written notice, HOME shall, within thirty (30) days after RESIDENT leaves, provide RESIDENT or RESPONSIBLE PARTY with an itemized written amount of funds, Including notification of funds still owed to HOME by RESIDENT or a refund owed to RESIDENT by HOME. 6.B RESIDENT Funds Procedure Following Discharge or Death of RESIDENT Upon discharge of RESIDENT, HOME shall return RESIDENT's funds being managed by HOME to RESIDENT or RESPONSIBLE PARTY. Upon the death of RESIDENT, HOME shall surrender to RESIDENT's estate funds and valuables of RESIDENT which were entrusted to HOME or left in HOME In addition, an itemized written account of RESIDENT's funds and valuables whletl were entrusted to HOME shall be surrendered within 30 worl\ing days of RESIDENT's death. A signed receipt shall be obtained and rntained by HOME 7. TERM, TERMINATION, TRANSFER, OR DISCIlAIlGE 7.1 Term of Agreement TIle term of this Agreement shall COll1mellce Oil tile date set f0l111 above and will 7 EXIIIPIT I!... PArir..:..l- remain In effect until it is terminated by eitl1er party as described herein or until a different or subsequent agreement is executed. Notification of adjustment in charges for basic or supplemental services and supplies sl1all be considered an amendment to tills agreement, but at tile time of sUet1 adjustment, execution of a different or subsequent agreement sl1all not be necessary to effect sucl1 cl1ange of rates. 7.2 Termination, Discharge or Transfer Initiated by RESIDENT RESIDENT or RESPONSIBLE PARTY may terminate this Agreement by giving advance written notice to HOME of RESIDENT's discharge from HOME. Obligation of RESIDENT or RESPONSIBLE PARrY solely from RESIDENT's financial resources, to pay HOME for services rendered tl1rough the date of discharge shall continue until such financial obligations l1ave been satisfied. RESIDENT or RESPONSIBLE PARTY may initiate RESIDENT's discharge at any time. RESIDENT will not be forced to remain in HOME against RESIDENT's will for any period of time. Requests by RESIDENT or RESPONSIBLE PARTY to transfer to another room will be subject to tile availability of tile room requested and the needs of RESIDENT and other residents. HOME will advise RESIDENT or RESPONSIBLE PARTY of any additional cl1arges for requested room if different than assigned room. 7.3 Termination, Discharge or Transfer Initiated by HOME HOME may terminate this Agreement by giving thirty (30) days advance written notice to RESIDENT or RESPONSIBLE PARTY. HOME may discharge or transfer RESIDENT only under the following conditions: a) transfer or discharge is necessary for RESIDENT's welfare and RESIDENT's needs cannot be met in HOME; b) RESIDENT's health has improved sufficiently and the services of HOME are no longer required, as documented by RESIDENT's physician; c) the health or safety of otllers at HOME is endangered; d) RESIDENT has failed, after reasonable notice, to pay for or have Medicare or Medicaid pay for, RESIDENT's stay at HOME; e) HOME ceases to operate. 8 EXHlA1T ._li- PAGE .J....- 7.4 Notice of Transfer or Discharge by Home In the event of transfer or discharge, HOME will provide advanco notice of thirty (30) days except wilen RESIDENT l1as urgent need for furtl1er medical altention, RESIDENT is absent from HOME for tl1irty (30) days, RESIDENT's l1ealt11 has Improved to tile extent tl1at tile services of HOME are no longer required, or RESIDENT's stay endangers tile l1ealtl1 or safety of otl1ers at the facility. At minimum, the notica will contain the following information: a) tile reason for transfer or discl1arge; b) the effective date of the transfer or discharge; c) tile location to whicl1 RESIDENT is to be transferred; d) a statement tl1atthe residentl1as tile right to appeal tile action to the Pennsylvania Department of Public Welfare, Office of Hearing and Appeals, P.O. Box 2675, Harrisburg, PA 17105.2675; e) the name, address, and telephone number of tile state long term care ombudsman (the local Area Agency on Aging); I) tile name, address, and telepl10ne number of the agency responsible for protection and advocacy of developmentally disabled individuals; g) tile name, address, and telepl10ne number of the agency responsible for the protection and advocacy of mentally ill persons. 8. RESIDENT RECORDS 8.1 Record Maintenance HOME shall maintain records in accordance with the requirements of federal and state governmental agencies or otl1er third party reimbursement sources. 8.2 Confidentiality and Authorization HOME acknowledges that RESIDENT's personal and medical records are confidenllal. RESIDENT or RESPONSIBLE PARTY authorizes access and use cf such records to HOME. In the event of RESIDENT's admission to a hospital or referral to other health care providers, RESIDENT or RESPONSIBLE PARTY authorizes the release of Inform all on to sucl1lnstitution or health care provider. In addillon, RESIDENT or RESPONSIBLE PARTY authorizes the release of Information on the medical record to third party payors or potential payors, government or regulatory agencies, the state ombudsman, and tile HOME's liability carrier or 9 EXHIA1T .il..- PAGE ~ HOME's legal counsel. 9, MEDICAL TREATMENT AUTHORIZATION 9.1 Authorization by RESIDENT or RESPONSIBLE PARTY HESIDENT or RESPONSIBLE PARl1' authorizes HOME to provide care and treatment consistent with the terms of this agreement. 10. THIRD PARTY PAYMENTS 10.1 Authorization to BI1I1l11rd Party payors RESIDENT or RESPONSIBLE PARTY authorizes HOME to bill any third party payor directly for service rendered which may be covered by any insurance or government assistance program, including Medicare, Medicaid, and private insurers. 10.2 Assignment of Medicare Payments RESIDENT or RESPONSIBLE PARTY requests that payment of authorized Medicare benefits be made on RESIDENT's behalf to HOME for any services furnished RESIDENT by HOME. RESIDENT or RESPONSIBLE PARTY authorizes any Ilolder of medical information about RESIDENT to release to the Health Care Financing Admlnistrallon and its agents any Information needed to determine these benefits or the benefits payable for related services. 11. MISCELLANEOUS PROVISIONS 11.1 Governing Law This Agreement shall be governed by and construed in accordance with the laws of the Commonwealth of Pennsylvania. 11.2 Severability II any of the provisions in this Agreement are declared to be invalid, such provisions shall be severed from the Agreement and the other provisions hereof shall romaln in full force and effect. 11.3 Headings Section headings contained in this Agreement are for reference purposes only and do not constitute part of this agreement. 11.4 Entire Agreement This Agreement together with HOME's Application for Admission, Schedule of 10 1)0 HIm L- PAGE ~ Charges, Resident Handbook, Resident Rights, policies on Advance Directives and Financial Assistance constitute the entire understanding between the parties with respect to the matter contained herein, superseding all prior and contemporaneous agreements and understandings, express or implied, oral or written. No addition or modification to this agreement may be made by RESIDENT or RESPONSIBLE PARTY without the consent of HOME, and such addition or modification shall be In writing signed by RESIDENT or RESPONSIBLE PARTY and a corporate officer of United Church of Christ Homes, Inc.. 11,5 Modlllcatlons HOME may modify or amend this Agreement unilaterally to assure compliance with subsequent changes in governing law or regulation. Notice of any such changes will be provided to RESIDENT or RESPONSIBLE PARTY. 11.6 Notices All notices required or permitted under this Agreement shall be in writing and shall be deemed to have been given, made and received when personally delivered or sent by regular U.S. Mail addressed to the party(ies) as set forth above. Any party may change the address to which notices are to be sent by giving notice of such change In the manner described above. 12. ACKNOWLEDGEMENTS 12.1 Schedule of Charges RESIDENT and RESPONSIBLE PARTY, if any, acknowledge receipt and understanding of HOME's Schedule of charges. 12.2 Resident Handbook RESIDENT and RESPONSIBLE PARTY, if any, acknowledge receipt and understanding of HOME's handbook on HOME's rules (Resident Handbook) and agrees to abide by HOME's rules. 12.3 Resident Rights RESIDENT and RESPONSIBLE PARTY, if any, acknowledge receipt and understanding of Resident Rights. 12.4 Advance Directives RESIDENT and RESPONSIBLE PARTY, if any, acknowledge receipt and understanding of HOME's policy on Advance Directives. 12.5 Financial Assistance RESIDENT and RESPONSIBLE PARTY, if any, acknowledge receipt and understanding of HOME's Financial Assistance policy. 11 EXHIBIT .iL PAG(..1.I.- 12,6 Agreement RESIDENT and RESPONSI8LE PARTY, if any, by virtue of signing this Agreement, declare that this Agreement has been fully explained and understood. IN WITNESS WHEREOF, the parties, Intending to be legally bound, have signed this agreement on the date written below. --"" [.L-\ ~ -€.AJ.e R - DENT ~ \tv\ Witness Witness Date S\~'\ \ 1'l Date ~~ ~. Pd4Y\/ SPONSIBLE PARTY ~~~ Relationship t Resident Witness 0-/';" 7/ff Date I 1/93 12 EXHIBIT L PAGE ...LA.. . ~;,' 1::'8.... C R:-, tt:e ~ .. -0, g = "~Jc:8"';'''t ',..... ..... Do ~}~.~4~ ~ I.;'.~'li$."~;:;: ~"Sij' - '. ,f.... '" ._~- .<c.~,~.:';i \ . '~.,. u. ~., N.. .~. . 1'- "' ~ 0' ~ " l.~ ~ Ul Ie ~ w " . ~j ~~. i~ ~ (t c ,,'" '" "' ~ " . L'I W '-.1 " In c x '" J' ~ " " ! t- r, " () .. 0 ~ (, ~ 0 0\ 0 W CI I ,. ili " v; w . _.~. .._.-....~._-_.---...~. -"" .. ':~ 1 Ii' 0 u w .:J ..;j ,. 0 H (fl ~ " . ~ 1 .1 w 0 :i.. ~ .,~ In 3 uJ (II '" ~i -.... "' i~;'1 0 -J ::f " 0 n Iv > '" ,.) U' oj <l "I' . aJ >- w u - >< w . '" (() u z Z II: > W '" ., .., 0 ~-i~. ,', j ,. n w 0 e ,. , Vl H U V' .. .-, '.. ' t: " Z ---~.._..- :J ~-_.- .._---._~---~ ... 'I .. " " ~ , c- ~ d '..''-. . 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