12/01/1981BAY SHORE MANOR A/KlA
i{O:�RO COC':�TY HO:iE, AD 'LT CO:�GREG:uiTE
LIVING FACILITY FOR THE ELDERLY - LE%'EL II
AGREEZIENT
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
Herbert C. Clark
hereinafter called "Resident", and None
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
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: To pay medicare deductible, 80% of
balance after medicare for 1st 14 days of
hospital care, 80% of balance after medicare
or p ysician services.
5. Other: To reimburse $10.00 per month
for personal spending money.
B.
RM
mTi T' D"QT7Fr7 nr-,
1. To nrc%,ic'e s,:c'i [,ersoniai clothing. a1-1c+
erLects .:s or clCsired
Resident.
2. To pay the monthly rate agreed upon and
such charges as determined by the Monroe
County Dome to be necessary_ for the
operation of the home.
3. That, upon certification by a physician
or the ?.cministrator of the Home, that
the Resident is no longer capable of
meeting the requirements for occupancy
in this facility, the Resident, next of
kin, ler.,al representative, or agency
acting on the Resident's behalf, will
be notified and the Pesident will have
to make arrangements for immediate
transfer_ to an appropriate facility.
In the event a Resident has no person
to represent him/her, this facility
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 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: None
FINANCIAL ARRANGr.:'FNTS
The Resident and/or responsible party agrees to
pay to the County $ 611.80
rent for use of the facilities.
, per month as
Payment will be fromthe following sources:
1. Personal funds of Resident $
2. Responsible party will pay $
3. Unearned income of Resident
will pay:
Social Security $ 338.10
Civil Service Annuity, $
VA Pension $ 273.70
Other 8
D. Sr 'tr: ^^ r.,T� T .. r�
i
The Count,, th-'ouch its e-mr1 to ( -es has aQr eC't t0
exercise such reasonable care toward the Resident 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%?anagement of this home will not be respon-
sible for any valuables or money left in the possession of
this person while he or she is a resident of this home.
E. TFRIMINATION
If Resident is absent from the home in excess of
fourteen (14) continuous days, such absence shall automa-
tically terminate this Agree:.ent 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. MEDICAL SERVICES
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. DUPATION OF AGRFE,!FNT
Either party may terminate this agreement on five
(5) days written notice. ethenaise, 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 length of .m.e.
-L/V�---
Witnesses as to Resident
G
Witnesses as to
Responsible Party
Signature of Resident
Signature of Responsible
Party
DATE
APPP.OVED:/?AMj ,V /L11'rm
Signature of Representative
of Monroe County dome aka
Bay Shore Manor
Sign ture of Executive
Director, Monroe County
Social Services
t 7 l
Sig pure of County
ACministrator
THIS IS TO CFRTIFY THAT THIS ADMISSION AGRFPMENT AS
APPROVED BY THE COUNTY HOME AN?D THE COUNTY ADS^_INISTPITOR
WAS R.ATIFIFD BY TuP MONROE COUNTY BOARD OF COUNTY
CO"_`•1IISSIONFRS AT THEIR MEF=IG HELD ON THE DAY
OF 177&. � 19—?4.
Siq ure of the Chai man
Monroe County Board of
County Commissioners