09/12/1995BAYSHORE MANOR
A/K/A MONROE COUNTY HOME
ASSISTED LIVING FACILITY
FOR THE ELDERLY
SHORT TERM RESIDENTIAL
A G R E E M E N T
This agreement entered into this 1N day of ,5ft6^ , 19 qJ ,
by and between the County of Monroe, State of Florida,
hereinafter called "COUNTY" and Ih A4 ,Poo kl-k
hereinafter called "RESIDENT", and /'I jk j-A/(,/Z l J ,
hereinafter called "RESPONSIBLE PARTY".
W I T N E S S E T H:
WHEREAS, RESIDENT desires to temporarily reside in the County
facility known as Bayshore Manor, for a period of:__I_day(s)
(NOT TO EXCEED THIRTY (30) DAYS) commencing on the day of
��m Qa 19 qjl" , and terminating at FA4 on the
^ day of ?ieft)k GdYZ- , 19 �� 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:
A. BAYSHORE MANOR:
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, as detailed
in Section C of this AGREEMENT. Refunds will not be
made for any days that personal belongings remain in
1
RESIDENT'S room nor as long as there are outstanding
expenditures for services received by RESIDENT.
4. Shall, in the event of closure of the facility for any
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 maintain no affiliation with any religious
organization, except to provide assistance to RESIDENT
in contacting such organization upon RESIDENT'S request.
6. Other
B. RESIDENT and/or RESPONSIBLE PARTY
1. Shall provide all clothing, medication, and personal
effects as required by RESIDENT during his/her residency
at Bayshore Manor.
2. Shall pay the full amount due upon executing this
AGREEMENT.
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
return to his/her home upon certification by either a
physician or the Director of Bayshore Manor that
RESIDENT is no longer capable of meeting the requirements
for continued residence in or use of the facility.
6. Shall maintain on file with Bayshore Manor an
up-to-date name, address and telephone number for
RESPONSIBLE PARTY or next of kin.
7. Shall provide RESIDENT'S personal physician with written
authorization to provide any medical care necessary
while RESIDENT is residing at Bayshore Manor under
terms of this AGREEMENT and provide Director of
Bayshore Manor with a copy of such authorization.
8. Other: K
C. FINANCIAL RESPONSIBILITY
RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY the sum of
SIXTY ($60.00) DOLLARS per day, with the total amount due for the
entire term of AGREEMENT at the time the AGREEMENT is executed.
D. STANDARD ADMISSION WAIVER
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.
E. RESIDENT PERSONAL CASH
RESIDENT shall at no time have in his/her possession on the
premises personal cash in excess of ONE HUNDRED ($100.00)
DOLLARS.
F. MEDICAL AND DENTAL SERVICES
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.
RESIDENT'S personal physician is:
NAME 91-IyPk fA l , 041� ,
ADDRESS %(ji %.1_V 9F, ('c 11 a
r� k) 4 Ft F L , 33 o,t D
PHONE ( Q5) a 7q- 6 � `t 2-
G. TERMINATION OF AGREEMENT
At the time that RESIDENT vacates Bayshore Manor 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 such property
3
after having made a reasonable effort to deliver it to RESIDENT
or RESPONSIBLE PARTY, without success.
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. AMENDMENTS TO AGREEMENT
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.
J. NOTICE
Any notice required by this agreement to be made by either party
shall be made as follows:
BAYSHORE MANOR
Name:ROBERT E. LAZARUS, M.D.
Address: 5200 College Road
Key West, F1. 33040
Phone: (305)294-4966
RESPONSIBLE PARTY
Name: �H,�`iPW
Address : 919 kALCH 0 El -
Key u1aT, FL . D nq 0
Phone: ODE) A93-0*77
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
proper jurisdiction and venue of any claims arising under this
agreement shall be in Monroe County, Florida.
L. POST -TERMINATION PRESENCE
4
COUNTY has no obligation to provide services except as stipulated
herein. Should RESIDENT remain on the premises of Bayshore
Manor after the expiration of the term, COUNTY may contact State
Protective Services and relinquish custody of RESIDENT thereto.
M-�
WITNE ES AS O RESIDENT
WIT NES ES AS TO RESPONSIBLE PARTY
DATE
DATE •
APPROVED:
SIGNATURE O RESIDENT
S
SIGNATURE OF DIRECTOR, BAYSHORE MANOR
SIGNATURE OF EXECUTIVE DIRECTOR,
MONROE COUNTY SOCIAL SERVICES DEPARTMENT
SIGNATURE OF MONROE COUNTY ADMINISTRATOR
APPROVED AS TO FO 7* 1
D LEGAL SUFFIC!
f'
Affom O: w
r -
5
BAYSHORE MANOR
A/K/A MONROE COUNTY HOME
ASSISTED LIVING FACILITY
FOR THE ELDERLY
AMENDMENT TO AGREEMENT
THIS AMENDMENT to AGREEMENT entered this %, day of
19 Q"-, by and between the County of Monroe, Florida, hereinafter
called "COUNTY" and R aA P0m aLz- , hereinafter
called "RESIDENT" and tom MARAS 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
1995, between the parties is hereby amended as follows:
Paragraph L, DISASTER PLAN: is added to read:
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 oA e AGREEMENT, dated the Wrday of
'5z: A74QXr. , 19 which are consistent herewith, shall
remain in full force and effect.
WI ES AS TCbRESIDENT
W E SES KS--Tt RESPONSIBLE
PAR J
DATE • r
C /
DATE • / )
APPROVED:
SIGNATURE 6F PSIDENT
SIGNA-TURE OF RESPONSIBLE PARTY
SI G14AT JR
BAYSHORE
SIGNATURE OF -EXECUTIVE DIRECTOR
SOCIAL SERVICES DEPARTMENT
SIGNATURE OF ADMINISTRATOR
MONROE, COUNTY, FLORIDA
APPROVED AS TO FOr
EGAL SUFF