12/01/1981r
BAY SHORE MANOR A/K�A
iiO::ROC COUNTY HO`IE, ADULT CO::GREGi:,�TE
LIVING FACILITY I`OR THE ELDERLY - LEVEL II
AGREEMENT
This Agreement entered into this 1st day of
December 19 81 by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Mary Floriette Albury
hereinafter called "Resident", and Hilk ry �Albury
Party"
, hereinafter called "Responsible
W I T N E S S E T H:
WHEREAS, the Resident desires to use the facilities
of the County known as The Monroe County Home, aka Bay Shore Manor -.
and, -
WHEREAS, the County has reviewed the application
s
of the Resident for admission to The Monroe County Home and
has determined that the Resident is eligible for admission
to said home, now, therefore,
IN CONSIDERATION of the mutual covenants, promises
and premises herein contained, the parties agree as follows:
A • BAY SHORE MANOR
1. To furnish room, board, linens, prescribed
medicines and general personal care.
2. To arrange for the transfer of the
Resident to the hospital of Resident's
choice, when ordered by the attending
physician or the health of the Resi-
dent requires same, and immediately
notify any responsible party (as
designated herein) of such transfer.
3. To make refunds in accordance with the
policy of the Home. Refunds cannot
be made as long as personal belong-
ings 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: None
5. Other: None
r
5.
C.
mryp nrcT' rF-
1. To provic'e suc': ^erso:.al clothin am
effect:.; as or c sired by t e
Resident.
2. To pay the monthly rate agreed upon and
such charges as deter_m.ined by the Monroe
County Home to be necessary for the
operation of the home.
3. That, upon certification by a physician
or the PrIministrator of the Home, that
the Pesident is no loncrer 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, will
be notified and the Pesident will have
to make arrangements for ir^mediate
transfer_ to an appropriate facility.
In the event a Resident has no person
to ren_resent him/her, this facility
shall assist Resident in contacting an
appropriate social service ar.ency for
placement. FPplicant agrees to vacate
the facility within forty-eight (48)
hours after disaualification.
4. To comply with all requirements as set
forth in the Application made by the
Resident.
5. To comply with all rules and regula-
tions established by the County for
operation and control of said home.
6. {Agrees, if not paying the maximum rate,
to pay any increases in in come during the
course of residency, up to the maximum rate.
7. Other: To be responsible for all hospital
and medical costs.
FINANCIAL ARPANGpi!FNTS
The Resident and/or responsible party agrees to
pay to the County $ 665.00
rent for use of the facilities.
, per month as
PaYment will be from the following sources:
1. Personal funds of Resident $
2. Responsible party will pay $ 665.00
3. Unearned income of Resident
will pay:
Social Security $
Civil Service annuity $
VA Pension $
Other $
Th? CnLrnt.' t:;r 11''T,, 1tS C:T;,,iloi'(,es has a(--'eri to
exercise such reasonable care toward the Resic'_ent as his or
her known condition may require, however, this home is in no
sense an insurer of his or her safety or welfare and assumes
no liability as such.
The 1%'_anaoement of this hor~,e will not be respon-
sible for any valuables or Toney left in the possession of
this person while he or she is a resident of this home.
E. TFMITTTAr`TOi\T
If Resident is absent from the home in excess of
fourteen (14) continuous days, such absence stall automa-
tically terminate this Agreement and the Resident shall
remove all of his or her property or belongings immediately.
If Resident fails to remove same, the Resident does hereby
authorize the County to remove said property or belongings
and deliver same to Responsible Party.
F. r1RT)T('7%.T. qF PUTr Pq
The parties agree that Monroe County shall not be
or assume any responsibility for payment of any medical or
hospital services, unless specifically agreed to by the
parties or their representatives at the time of the render-
ing of service.
G. T)TTRA",'T()NT 07 7\,(,1?T77 ;1V\TT
Fither party may terminate this agreement on five
(5) days written notice. Othertaise, it will remain in
effect until a different agreement is executed. However,
this does not mean that a Resident wil be forced to remain
in the facility against his/her will for any lena,th of time.
6
Plitnesses as to Resident
Witnesses as to
Responsible Party
i
Signa ure of Resident
Sic-nat7gre of Responsi e
P..rty
DATE idACTMl
APPROVED:
�pjl#.�1 f�
Sign ture lyepresentative
of Monroe County Home aka
Bay Shore Manor
2L%-�—AC-74 4a.,t-
Signature of Fxecutive
Director, Monroe County
Social Services
Si'geiature of County
Administrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGPFFMENT AS
APPROVED BY THE COUNTY HOME AND THE COUNTY AD�-'*IT?ISTR�TOR
WAS RATIFIFD BY THE MONROE COUNTY BOARD OF COUNTY
Com-%IIISSIOrJFR AT THEIR. MEETING HELD ON THE_�_DA.Y
O A 19.
C- �f 6-il d"�
0./
ign ure of the Chairman
Monroe County Board of
County Commissioners