12/12/1986 AgreementBAVSHORE MANOR A/K/A
MONRCE COUNTY HOME, ADULT CONGPEGATE
LIVING FACILITY FOR THE ELDERLY - LEVEL II
A G R E E M E N T
THIS AGREEPIENT ENTERED INTO THIS 12th DAY OF
December , 19 86 , BY AND BETWEEN THE COUNTY OF "JCNROE,
STATE OF FLORIDA, HEREINAFTER CALLED "COUNTY", AND Dorothy T. Aguero
HEPEINAFTEP CALLED "RESIDENT", AND Dttilee Sorken and Renee
Barringer , HEREINAFTER CALLED "RESPONSIBLE PAPTY",
W I TN E S S ETH:
WHEREAS.. THE PESIDENT DESIRES TO USE THE FACILITIES OF THE
COUNTY KNOWN AS THE MONROE COUNTY HOME, a/k/a/ BA.YSHORE MANOR AND,
WHEREAS, THE COUNTY HAS REVIEWED THE APPLICATION OF THE
RESIDENT FOR AfMISSION TO THE MONROE COUNTY HOME AND HAS DETEFMIN'ED THAT
THE RESIDENT IS ELIGIBLE FOR A. 4ISSION TO SAID HOME, NOW, THEREFORE,
IN CONSIDERATICN OF THE MUTUAL COVENANTS, PROMISES AND PREIISES
HEREIN CONTAINED, THE PARTIES AGREE AS FOLLOWS:
A. BAVSHORE MANOR
1. TO FUPNISH ROOM, BOARD, LINENS, PRESCRIBED MEDICINES AND
GENERAL PERSONAL CAPE.
2. TO ARPA.NGE FOR THE TRANSFER OF THE PESIDFNT TO THE HOSPITAL
OF THE RESIDENT'S CHOICE, WHEN ORDERED BY THE ATTENDING
PHYSICIAN OP THE HEALTH OF THE RESIDENT REQUIRES SAff, TO
IMMEDIATELY NOTIFY ANY RESPONSIBLE PARTY (AS DESIGNATED
HEREIN) OF SUCH TRANSFER.
3. TO MAKE REFUNDS ON A PER DIEM BASIS IN ACCORD WITH DATE OF
DISCHAFGE FROM THE HOME. REFUNDS CANNOT RE ,11A.DE AS LONG AS
PERSONAL BELONGINGS REMAIN IN THE RESIDENT'S ROOM. REFUNDS
CANNOT BE MADE AS LONG AS ,THERE ARE OUTSTANDING EXPENDITURES
FOR SERVICES RECEIVED BY THE RESIDENT.
4. OTHER: To pay medicare deductible, 80% of balance
after medicare for first 14 days of hospital care,
80% of balance after medicare for physician services.
5. OTHER: Bay Shore Manor will not be responsible for dental
care expenses.
B. THE RESIDENT OR RESPONSIBLE PARTY
1. TO PROVIDE SUCH PERSONAL CLOTHING AND EFFECTS
AS NEEDED OR DESIRED BY THE RESIDENT.
2. TO PAY THE MONTHLY RATE AGREED UPON AND SUCH
CHARGES AS DETERMINED BY THE MONROE COUNTY HOME
TO BE NECESSARY FOR THE OPERATION OF THE HOME.
3. THAT, UPON CERTIFICATION BY A PHYSICIAN OR THE
ADMINISTRATOR OF THE HOME, THE RESIDENT IS NO
LONGER CAPABLE OF MEETING THE REQUIREMENTS FOR
OCCUPANCY IN THIS FACILITY, THE RESIDENT, NEXT OF
KIN, LEGAL REPRESENTATIVE OR AGENCY ACTING ON THE
RESIDENT'S BEHALF, (DILL HAVE TO MAKE ARRANGEMENTS
FOR THE IMMEDIATE TRANSFER TO AN APPROPRIATE FACILITY.
IN THE EVENT A RESIDENT HAS NO PERSON TO REPRESENT HIM/HER,
THISFACILITY SHALL ASSIST RESIDENT IN 'CONTACTING AN
APPROPRIATE SOCIAL SERVICE AGENCY FOR PLACEMENT. APPLICANT
AGREES TO VACATE THE FACILITY WITHIN FORTY-EIGHT (48)
HOURS AFTER DISQUALIFICATION.
4. TO COMPLY WITH ALL REQUIREMENTS AS SET FORTH IN THE
APPLICATION MADE BY THE RESIDENT.
5. TO COMPLY WITH ALL RULES AND REGULATIONS ESTABLISHED BY
THE COUNTY FOR OPERATION AND CONTROL OF SAID HOME.
6. AGREES, IF NOT PAYING THE MAXIUM RATE, TO PAY ANY INCREASE
IN INCOME DURING THE COURSE OF RESIDENCY, UP TO THE MAXI-
MUM RATE.
7. OTHER: To assume the cost of dental care expenses
and to pay BC/BS health insurance premiums.
C. FINA.NCIAL ARRANGEMENTS
THE RESX.DENT AND/OP RESPONSIBLE PARTY AGREE (S) TO PAY TO THE
COUNTY $480.66 PER MONTH AS RENT FOR USE OF THE FACILI-
TIES.
PAYMENT WILL BE FROM THE FOLLOWING SOURCES:
1. PERSONAL FUNDS OF RESIDENT $
2. RESPONSIBLE PARTY WILL PAY $
3. UNEARNED INCOME OF RESIDENT
WILL PAY
SOCIAL SECURITY $ 169.00
CIVIL SERVICE ANNUITY $ 311.66
V.A. PENSION $
OTHER $
D. STANDARD ADMISSION WAIVER
THE COUNTY, THROUGH ITS EMPLOYEES, HAS AGREED TO EXERCISE SUCH
REASONABLE CARE TOWARD THE RESIDENT AS HIS OR HER. KNOWN CONDITION MAY RE-
QUIRE. HOWEVER, THIS HOME IS IN NO SENSE AN INSURER OF HIS OR HER SAFETY
OR WELFARE AND ASSUMES NO LIABILITY AS SUCH.
THE MANAGEMENT OF THIS HOME (DILL NOT BE RESPONSIBLE FOR ANY
VALUABLES OR MONEY LEFT IN THE POSSESSION OF THIS PERSON WHILE HE OR SHE
IS A RESIDENT OF THIS HOME.
E. TERMINATION
IF RESIDENT IS ABSENT FROM THE HOME IN EXCESS OF FOURTEEN (14)
CONTINUOUS DAYS, SUCH ABSENCE SHALL AUTOMATICALLY TERMINATE THIS AGREEMENT
AND THE RESIDENT SHALL REMOVE ALL OF HIS OR HER PROPERTY OR BELONGINGS IM-
MEDIATELY. IF RESIDENT FAILS TO REMOVE SAME, THE RESIDENT DOES HEREBY
AUTHORIZE THE COUNTY TO REA40VE SAID PROPERTY OR BELONGINGS AND DELIVER SAME
TO RESPONSIBLE PARTY.
F. MEDICAL SERVICES
THE PARTIES AGREE THAT MONROE COUNTY SHALL NOT BE RESPONSIBLE
FOR OR ASSUME ANY RESPONSIBILITY FOR PAYMENT OF ANY MEDICAL OR HOSPITAL
SERVICES, UNLESS SPECIFICALLY AGREED TO BY THE PARTIES OR THEIR REPRESENTA-
TIVES AT THE TIME OF THE RENDERING OF SERVICE.
G. DURATION OF AG RFEM ENT
EITHER PARTY MAY TERMINATE THIS AGREEMENT ON THIRTY (30) DAYS
WRITTEN NOTICE. OTHEFWISE, IT WILL REMAIN IN EFFECT UNTIL A DIFFERENT
AGREEMENT IS EXECUTED. HOWEVER, THIS DOES NOT MEAN THAT A RESIDENT WILL BE
FORCED TO REMAIN IN THE FACILITY AGAINST HIS/HER WILL FOR ANY LENGTH OF TIME.
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SIGNATURE OFSDN I �
WITNESSES AS TO RESIDENT
i ness o'.esponsible Party
Witness as to Responsible Party
WITNESS AS TO RESPONSIBLE PARTY
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SIGNATURE RESPONSIBLE PARTY
SIGNATURE OF RESP( NS BLS RTY
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DATE: \?.— \? — Iq-&(a
APPROVED:
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G.
Signature of Lepresentative
of Monroe County Hoiae a/k/a/
Bayshore Manor
Signature of Executive
Director - Monroe County
Social Services
S g ature of County
Administrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGREEMENT AS APPROVED
BY THE COUNTY HOME AND THE COUNTY ADMINISTRATOR WAS RATIFIED
BY THE MONROE COUNTY BOARD ,0-_' COUNTY COMMISSIONERS AT THEIR
MEETING HELD ON THE 46 `t- ` DAY OF
19 8', .
Signat e o the Chairman
Monroe County Board of
County Commissioners