12/01/1981BAY SHORE MANOR A/K/A
NO::ROE COUNTY HO:-,E, ADULT CO::GREC?.ATE
LIVING FACILITY FOR THE ELDERLY - LE�� EL II
A G R E E M E N T
This Agreement entered into this 1st day of
December , 1981 , by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Ina Kathleen Doty ,
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:
.•-14MM10061:
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 halance after medicare
for physicians services
5. Other: To reimburse resident S 10.00
per month for versona-L spending funds,
t,.
1. To .�rovic"e such" rerson�l clothin' anC'
ef-Fects as nee,_ ,d or c sired b�
Resident.
2. To pay the monthly rate agreed upon and
such charges as determinec? by the Monroe
County Home to be necessary for the
operation of the home.
3. That, upon certification by a physician
or the P.dministrator of the Home, that
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, 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 conta.ctina an
appropriate social service agency fer
placement. Applicant 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: None
C. FINANCIA.L AP.PANGFiIFNTS
The Resident and/or responsible party agrees to
pay to the County $ 265.65 per month as
rent for use of the facilities.
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 Securitv
Civil Service `�.nnuit-y
VA Pension
Other
$ I�4 g
$ 106.35
S
r
D. S . i n s•. ._ .. , . r c T r... ..7 T'.71F -)
Th ' Ccun tv tnrcu';h its e 1T?1.O''E eS .1as a<i r eCl t0
exercise such reasonable care towarcd 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 Management of this horse will not be respon-
sible for any valuables or 'Honey left in the TDossession of
this person while he or she is a resident of this horr.e.
E. TFRIMINATION
If Resident is absent from the home in excess of
fourteen (14) continuous days, such absence shall 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. MFDTC'A.T, SfiRVTr-r.q
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. DUP4TION OF AGRFF',TFyT
Fither party may terminate this agreement on five
(5) days written notice. Other;,,7ise, 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 time.
Witnesses as to Resident
Witnesses as to
Responsible Party
Signature of Reside t
Si_rnature of Responsible
Party
DATF lb4L, , //, / 9,?Z
APPROVED:
L� lLet"j
Signature Representative
of Monroe County Home aka
Bay Shore Manor
Signature of Fxecutive
Director, Monroe County
Social Services
------------
Sim ature of County
Administrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGRFFPIFNT AS
APPROVFD BY THE COUNTY HOME AND THE COUNTY ADr^.INISTRATOR
WAS R.ATIFIFD BY THE MONROF COUNTY BOARD OF COUNTY
COi%L%1ISSIONFRS AT THEIR MEFTING HELD ON THE , DAY
OF .I� 19 Z .
Signature of the Chairman
Monroe County Board of
County Commissioners