01/16/1987BAVSHORE MANOR A/K/A
MONROE COUNTY HOME, AfULT CONGREGATE
LIVING FACILITY FOR THE ELDERLY - LEVEL II
A G R E E M E N T
THIS AGREEMENT ENTERED INTO THIS 16th DAY OF
January P 19 87 , BY AND BETWEEN THE COUNTY OF MONROE,
STATE OF FLORIDA, HEREINAFTER CALLED "COUNTY", AND
Blanche V. Collins
HEREINAFTER CALLED "RESIDENT", AND
Jean Gregory and Madeline Cramer
HEREINAFTER CALLED "RESPONSIBLE PARTY",
WITNESSETH:
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 AD'iISSION TO THE MONROE COUNTY HOME AND HAS DETERMINED THAT
THE RESIDENT IS ELIGIBLE FOR ADMISSION TO SAID HOME, NOW, THEREFORE,
IN CONSIPEPATION OF THE MUTUAL COVENANTS, PROMISES AND PREMISES
HEREIN CONTAINED, THE PA.PTIES AGREE AS FOLLOWS:
A. BAVSHORE MANOR
1. TO FU PNISH ROOM, BOARD, LINENS,XNXX AND
GENERAL PERSONAL CARE.
2. TO ARRANGE FOR THE TRANSFER OF THE RESIDENT TO THE HOSPITAL
OF THE RESIDENT'S CHOICE, WHEN ORDERED BY THE ATTENDING
PHYSICIAN OP THE HEALTH OF THE RESIDENT REQUIRES SAME, 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 BE MADE 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 80% of balance after medicare and
supple en a insurance payment for t e first _r4_ a s
of hospital care, 80% of balance after medicare and
supplementaI insurance payment for physician's
services.
5. OTHER: Bayshore Manor will not be responsible for dental
care expenses, hearing aid expenses and prescribed
�Pr�i �ineS
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 DFTEWINED BY THE MONROE COUNTY HOME
TO BE NECESSARY FOR THE OPERATION OF THE HOME.
3. THAT, UPON CERTIFICATION BY A PHYSICIAN OR THE
AWINISTPATOR 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
FOP 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.
G. AGREES, IF NOT PAYING THE MAXIUM RATE, TO PAY ANY INCREASE
IN INCOME DURING THE COURSE OF RESIDENCY, LIP TO THE MAXI-
MUM RATE.
7. OTHER: To assume the cost of dental care expenses,
prescIfibed medicines, nearing aid expenses, an o
pay AARP Group Health Insurance premiums.
C. FINANCIAL ARRANGEMENTS
THE RESUENT AND/OR RESPONSIBLE PARTY AGREE (S) TO PAY TO THE
COUNTY $ 418.00 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
CIVIL SERVICE ANNUITY
V.A. PENSION
OTHER
R
$ 418.00
D. STANDARD A94ISSION 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 WILL 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 REMOVE 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. LURATION OF AGREEMENT
EITHER PARTY MAY TERMINATE THIS AGREEMENT ON THIRTY (30) DAYS
WRITTEN NOTICE. OTHERVISE, 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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APPROVED: 1p
S' nature f Representative
Of Monroe County Home a/k/a/
Bayshore Clanor
Signature of Executive
Director - ;•Monroe County
Social Services
Signature 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 OF COUNTY CO"% SS OTTERS AT THEIR
MEETING IiELD ON THE DAY OF ,
19.
Signature of e Chairman
Monroe County Board of
County Commissioners