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11/04/1996 AgreementG r BAYSHORE MANOR A/K/A MONROE COUNTY HOME ASSISTED LIVING FACILITY FOR THE ELDERLY A G R E E M E N T This agreement entered into this � day of 1976, by and between the County of Monroe, State of Florida, hereinafter called "COUNTY" and 1141knA-7dQ11,E R0-Q hereinafter called "RESIDENT", and JXAfJ-0iSR,) hereinafter called "RESPONSIBLE PARTY". W I T N E S S E T H: WHEREAS, RESIDENT desires to live in the County facility known as Bayshore Manor, and WHEREAS, COUNTY has reviewed RESIDENT'S application for admission to Bayshore Manor and has determined that RESIDENT is eligible for admission, now therefore, In consideration of the mutual covenants, promises and premises herein contained, the parties agree as follows: 1. Shall furnish room, board, linens and assistance with activities of daily living as may be required, based upon RESIDENT'S mental and/or physical limitations both at and subsequent to the time of admission. 2. Shall arrange for transportation of RESIDENT to his/her physician's office and/or arrange for RESIDENT'S transportation to hospital if such transportation is ordered by physician or if, in the opinion of the Director or his surrogate, RESIDENT'S condition so warrants. The RESPONSIBLE PARTY (as designated herein) will be immediately notified if RESIDENT requires hospitalization. 3. Shall make refunds on a per diem basis commensurate with the date of discharge from Bayshore Manor. Refunds will not be made for any days that rF'° personal belongings remain in RESIDENT'S room. Refunds will not be made as long as there are"t. outstanding expenditures for services received by RESIDENT. Nov I 1�1 4. Shall, in the event of closure of the facility fo y 1996 reason, make a pro -rated per diem refund as of the date of such closure. Such applicable refund will be made within SEVEN (7) DAYS of closure, in compliance with Florida Statutes. 5. Shall notify RESIDENT and/or RESPONSIBLE PARTY in writing THIRTY (30) DAYS in advance of any rate change. 6. Shall maintain no affiliation with any religious organization, except to provide assistance to RESIDENT in contacting such organization upon RESIDENT'S request. 7. Subject to the availability of funds, shall pay for such medications as may be prescribed for RESIDENT by his/her physician, as well as necessary non-prescription medical supplies, provided that RESIDENT'S monthly rate under this agreement is less than maximum rate and RESIDENT has insufficient medical insurance to cover such expenses, or in the event that RESIDENT'S monthly rate under this agreement is the maximum rate but RESIDENT has neither sufficient additional funds nor sufficient medical insurance to pay for the above. 8. Shall provide to RESIDENT whose monthly rate is less than the maximum rate, or who is paying the maximum rate and has no additional funds, on a monthly basis, TWENTY ($20.00) DOLLARS for his/her personal use. Such monthly reimbursements will be skipped or reduced any month when full payment would result in RESIDENT having more than ONE HUNDRED ($100.00) DOLLARS in his/her possession; or any month that RESIDENT receives funds for personal use of up to TWENTY ($20.00) DOLLARS, from any source, such as OSS, etc., to the extent necessary to assure RESIDENT of at least TWENTY ($20.00) DOLLARS for personal use. +� 9. Other: WA is . o. FrOTM Z14 *11 -Ok 1. Shall provide all clothing and personal effects as required by RESIDENT. 2. Shall pay the agreed upon monthly rate no later than the third day of each calendar month. 3. Shall comply with all requirements set forth in the application for admission. 4. Shall fully comply with all rules and regulations as now established by COUNTY or as may, in the future, be amended or established. 5. Shall make arrangements for RESIDENT'S immediate transfer to an alternative, appropriate facility upon certification by either a physician or the Director of Bayshore Manor that RESIDENT is no longer capable of meeting the requirements for residence in the facility. In the event that RESIDENT has no person or agency, whether RESPONSIBLE PARTY, next of kin or other person or agency appointed to act on RESIDENT"S behalf to represent him/her, Bayshore Manor shall assist RESIDENT in contacting an appropriate social service agency for placement. RESIDENT agrees to vacate the facility within SEVEN (7) DAYS after disqualification. 6. Shall, if RESIDENT is not paying the maximum rate, pay any increase in RESIDENT'S income (from any source) to COUNTY during his/her stay at Bayshore Manor, up to but not exceeding the maximum rate as may from time to time be adjusted by COUNTY. 7. Shall, if funds for medication expenditures become unavailable, make arrangements for payment of medication expenses which Bayshore Manor cannot pay or arrange for RESIDENT'S transfer to an alternative, appropriate facility. 8. Shall maintain on file with Bayshore Manor an up-to-date name, address and telephone number for RESPONSIBLE PARTY or next of kin. 9. Other:(I) SHAD. MY Fog At-L /VlZDA-ri-04/J Q&Mvab WAI'De='JI J1 cJv:t1Y,Jt icti Ahi #J01 ftl A)r 6Y 51i,4,LL CosgjM)Z Tp PAY R35►9a►sY''J J"d CA49S, 9LdX 3A,4b 1Nd941yaAWLhS xM -4,4£ � 8Y 221 brut RESIDDENT and/or RESPONSIBLE PARTY agree to pay COUNTY $ tyc io J per month for use of COUNTY'S Bayshore Manor facility. Monthly payment shall be derived from the following sources: 1. Personal funds of RESIDENT $ -�- 2. RESPONSIBLE PARTY will pay $ —� 3. Monthly income of RESIDENT: Social Security income $ t,.sg. Supplemental Security Income $ Railroad Retirement income $ Civil Service income $ V.A. Pension $ �1 Other $ $ 3 COUNTY shall continually exercise such reasonable care as to maintain the health and safety of RESIDENT. However, COUNTY does not provide any assurance or guarantee for RESIDENT'S health and safety and shall have no liability for same. COUNTY shall have no liability or responsibility for cash or other valuables which RESIDENT may, at any time, have in his/her possession on the premises of Bayshore Manor. RESIDENT shall hold COUNTY harmless for any and all claims arising directly or indirectly from any negligent or intentional act of RESIDENT. RESIDENT shall at no time have in his/her possession on the premises personal cash in excess of ONE HUNDRED ($100.00) DOLLARS. COUNTY shall not be responsible for the payment of any medical, chiropractic, dental or hospital bill incurred by RESIDENT. Furthermore, COUNTY shall not be responsible for the payment of RESIDENT'S "over-the-counter" or prescription medications except as detailed in paragraph A-7, above. In the event that RESIDENT vacates Bayshore Manor for more than FOURTEEN (14) consecutive days, except for hospitalization, this agreement shall automatically terminate, and RESIDENT or RESPONSIBLE PARTY shall remove all of RESIDENT'S personal property immediately. If property is not removed in a timely fashion, the parties agree that COUNTY is authorized to remove and dispose of 4 such property after having made a reasonable effort to deliver it to RESIDENT or RESPONSIBLE PARTY, without success. In addition to the methods of terminating this agreement, detailed in Paragraphs B-5 and G, above, it may be terminated by RESIDENT upon written notice to COUNTY at any time. Additionally, COUNTY may terminate the agreement upon THIRTY (30) DAYS written notice to RESIDENT of RESPONSIBLE PARTY, certified mail, return receipt requested. H. DURATION OF AGREEMENT Unless otherwise terminated, this agreement shall remain in full force and effect until such time as a new agreement is duly executed. I. AMENL This agreement may be amended at any time subsequent to its execution by both parties, or their legal representatives, by the parties or their legal representatives signing and executing such an amendment. in Any notice required by this agreement to be made by either party shall be made as follows: BAYSHORE MANOR RESIDENT/RESPONSIBLE PARTY Name:ROBERT E. LAZARUS, M.D. Name: T AfJ DU RJ.D Address: 5200 College Road Address: 07 WNrtd 14,M 37, _ Key West, Fl. 33040 Kpy W4t EL. 3300 Phone: (305) 294-4966 Phone:(305� '2k- 0777 Parties may substitute the above by proper notice. K. FLORIDA LAW Both parties shall at all times comply with the Laws of the State of Florida and Monroe County. Further, RESIDENT agrees that the 5 proper jurisdiction and venue of any claims arising under this agreement shall be in Monroe County, Florida. WITNESSES AS TO RESIDENT AL.11) L l WITNESSES AS TO RESPONSIBLE PARTY DATE: DATE: P-31-f Y APPROVED: SIGNATURE OF RESIDENT SIGNATURE OF RESPONSIBLE PARTY SIGNATURE 66F DIRFWOR, BAYSHORE MANOR SIGNATURE OF EXECUTIVE DIRECTOR, MONROE COUNTY SOCIAL SERVICES DEPARTMENT SIGNATURE OF MONROE COUNTY ADMINISTRATOR APPROVE AS TO FORW 4DATE-- SUFFICI NE A. ON BAYSHORE MANOR A/K/A MONROE COUNTY HOME ASSISTED LIVING FACILITY FOR THE ELDERLY THIS AMENDMENT to AGREEMENT entered this day of MOJuflxvkl'^..r 19 56, by and between the County of Monroe, Florida, hereinafter called "COUNTY" and i41L-64 ,S4'0Y frAa.D hereinafter called "RESIDENT" and Tgnp b1cavo hereinafter called "RESPONSIBLE PARTY". WHEREAS, COUNTY has a primary responsibility for the safety of the residents of Bayshore Manor; and WHEREAS, there exists in Key West, Florida the possibility of a life threatening hurricane or other natural or man made disaster occurring which, in the sole discretion of County, will require the evacuation of the Bayshore Manor facility; and WHEREAS, either a natural or man made disaster might be of such a nature as to result in either a partial or complete destruction of the Bayshore Manor facility so as to render the structure uninhabitable and require alternative residential placement of RESIDENT on either a temporary or permanent basis; now, therefore IN CONSIDERATION of the mutual covenants herein contained, the parties agree as follows: The AGREEMENT entered on the day of poid" oL, , 19 � b , between the parties is hereby amended as follows: 1. If either a natural or man made disaster requires the evacuation of the Bayshore Manor facility; and 2. If, such a disaster causes such extensive damage to the Bayshore Manor facility as to render the structure uninhabitable, in the judgement of COUNTY; and 3. If, RESPONSIBLE PARTY has not evacuated RESIDENT from Bayshore Manor, for any reason; then 4. COUNTY has the absolute right to temporarily transfer RESIDENT to a shelter, either within or outside of Monroe County, until such time as the disaster requiring the evacuation has ended and County has assessed the extent of the damage to the Bayshore Manor facility. 5. If COUNTY determines that, as a result of the disaster, the Bayshore Manor facility is uninhabitable, COUNTY has the absolute right to transfer RESIDENT to an alternative Adult Congregate Living Facility of its choice within the State of Florida. 6. If County transfers RESIDENT to an alternative Adult Congregate Living Facility, County will make a reasonable effort to advise RESPONSIBLE PARTY of such a transfer. 7. If RESPONSIBLE PARTY removes RESIDENT from the ACLF in paragraph 6, except to return RESIDENT to a safely reconstructed Bayshore Manor, or enters into a separate agreement with said ACLF, this Agreement, as amended shall terminate immediately. 8. All other terms of the AGREEMENT, dated the day of A bd6ALJ2 4 , 19?�P, which are consistent herewith, shall remain in full force and effect. WIT SES AS TO RESIDENT lda WITNESSES AS TO RESPONSIBLE PARTY DATE : ///4/9 6 DATE: D 3 SIGNATURE OF RESIDENT SIGNATURE OF RESPONSIBLE PARTY SIGNeLRE OF DIRECTOR BAYSHOR !, SIGNATURE OF EX$CUTIVE DIRECTOR SOCIAL SERVICES DEPARTMENT APPROVED SIGNATURE OF ADMINISTRAT R MONROE, COUNTY, FLORIDA APPROVED AS TO FORM AND LEGAL SUFFICIEN BY NNE A H ®N DATE __...._.