03/17/1987 AgreementBAY SHORE MANOR
A/K/A MONROE COUNTY HOME
ADULT CONGREGATE LIVING FACILITY
FOR THE ELDERLY - LEVEL II
A G R E E M E N T
TW agreement enteAed .into thi6 17th day o6 March
, 19 87 , by and between the County ob Monnoe, State of
Fton i.da, heAei.nabten caned "County", and W iZZiam Ett eu
here i.nabteA caP.eed "Re6 ident", and
heAeinabter caned "Res pontsibt e Patcty",
(dTTNF-qSFT14:
WHEREAS, the &aident desiva to use the 6ac Zity o6 the County
known ass the Monnoe County Home, a/k/a Bay Shone Manotc and,
WHEREAS, the County ha6 Aev.iewed the apptication of the v/s dent jots
adm,bs,6ion to the Montwe County Home and has detenm.ined that the te/s.ident is
et ig.ibte JoA admission to said home, now, theAe6one,
In consideration ob the mutua.2 covenant6, pAom-cza and pnem.uses
herein contained, the pantie6 agree a6 jottows :
A. BAY SHORE MANOR
1. To 6uAni6h room, board, tinenis, ptre,,enibed medicines
and geneAat peuonat carte.
2. To annang e �oA the txan,5 b eA o6 the tmident to the
hozpitat o6 the Am ident'z choice when oAdeAed by the
attending physician on the health ob the te�sident
nequ.vre6 same, and to immedc.ateey noti6 y any
nezpon,sibte panty (as designated heAei.n) o6 .such ttrans6a-
3. To make ne6unds on a pets diem b"i6 in, accord with date
ob dvschange 6Aom the home. Re6unds cannot be made as
.bong aus peAzonat betong.ingz remain in the tezident',s
room. Re6unds cannot be made a3 .bong ass theAe cure
out6tanding expenditaez Got 6e&v.ices nece%ved by the
nes.ident.
4. In the event ob c2ozune o6 the 6ac t ty bon any reason,
a pro -rated peA diem ne6und shaet be made in accord
with date o6 ctosune.
5. Other:
B. THE RESIDENT OR RESPONSIBLE PARTY
1. To pntov.ide 6uch petsonal c2oth,in.g and e66ect6 as
needed oA desited by the to ident.
2. To pay the monthly Aate agued upon and such
changes as detenm.ined by the Monroe County Home
to be necu4any bon, the opeAation o6 the home.
3. That, upon ceAti6.icat.ion by a physician oA the
adm.imiztAato,t o6 the home, the Aes,ident is no
longeA capable o6 meeting the tequ Aement6 bon
occupancy .in th" 6 ac c.P,it y, the tes.ident, next o6
Fun, legal AepAesentative on agenco acting on the
Aes.ident',s behal6, w.i.?.Q. have to make aAkangements
6oA the immediate tAan66en to an appAopAiate 6aueity.
In the event a Aes.ident has no peas on to AepAes ent
h.im/heA, th is 6acc.Uty shaU assist to ident .in
contacting an appAopn,iate Social Service Agency 6oA
placement. Appticant ag teu to vacate the 6acc.2.ity
within bon ty- eight (48) houAz a6ten d us quat i..6icati.on.
4. To comply with aU AequiAements as set 6 onth..in the
apptication made by the Aes,ident.
5. To comply with aU nines and Aegulations estabt"hed
by the County 6oA ope4 Lion and contAol o6 za,id home.
6. Ag&e", i6 not paying the maximum Rate, to pay
.incAea,se .in .income fluxing the counoe o6 tuidency,
up to the maximum Rate.
7. OtheA: Aq teez to loan all medical expenses
including medicines.
C. FINANCIAL ARRANGEMENTS
The tes ident and/oA ALuponzible panty agn.eu to pay to the
County $ 1195. 00 , peA month ass Aent 6oA use o6 the 6acc.P,ctiez.
PAYMENT WILL BE FROM THE FOLLOWING SOURCES:
1. Petvsonal 6un6 o6 Aesident
2. Ru pomible panty w tt pay
3. Unearned income ob Ae6.ident
w,i Qt pay:
Social SecuA.ity
Civil SeAv.ice Annuity
V.A. Penz ion
OtheA
$ 1195, 00
2
D. STANDARD ADMISSION WAIVER
The County, through its emptoyeea, hays agreed to exenc,ise such
Aeasonab.le cane toward the Aes.ident as h z on hen known condition may tequiAe.
However, this home is .in no zenze an .inzureA o� his arc hen r6a6ety on wet6ane
and asrsumes no tiab•i?,ity ass Such.
The management ob this home wit not be Ae�sponrs ibte bon any
vaQuab• a orL money te6t ,in the po�szas.ion o6 th,v6 peon white he oA she is
a Aez ident o6 this home.
E. TERMINATION
I� rcez ident is ab.5ent bnom the home in excersr6 ob bouAteen (14)
continuows days, such absence sha t automaticatty teAminate this agreement
and the to ident 6haU Remove a t ob hvs oA heA pAopercty oA be.longings
.immed•i•atety. Ib taident 6ai.,6 to remove 6ame, the na.caenz aoel5 nvLeoy
autho,t ze the County to remove said property oA belongings and deei.veA same
to rLaponz ibte panty.
F. MEDICAL SERVICES
The parti m agree that Monroe County zha t not be Aezponz.ibte bor
on assume any tesponz ibit ty 6or payment o6 any medical on hospital seAvice6
un•1uz z peaib.iea t y agreed to by the panty a or thedtc rep te/s entativ e,6 at the
time ob the tendering o6 seAvice.
G. DURATION OF AGREEMENT
EctheA panty may teAminate this agreement on thi ty (3 0) days
wxitten notice. Othe uvis e, it witt remain .in eb 6 ect unt t a dlib 6 eAent
agreement is executed. However, this does not mean that a Aesident w,itt be
boneed to remain .in the �aciZ ty against his/het w,itt bor any .length o6 time.
WITNESSES -AS TO RESIDENT
SIGNATURE F RESPONSIBLE P RTy
WITNESSES T RESPONSIBLE PARTY
- - - - - - - - - - 3 - - -
DATE: WaAA
�� 19 g7
APPROVED: ` 1
M 1 /11
skg naxune Vunty
xepnezentatkve
o� Monnoe Home a/k/a
Bay Shone Manors
Sig natune o Executive
DiAecto)L--Monroe County
Sociat Services
cg u e o County
AdministAatoA
This is to ce,%tij y that this Admission AgAeement as appnov ed by
the County Home and the County AdministAatoA was tatijied by the
MonAoe County Boand o6 County Commizzionenz at their meeting
head on the .17 day o6 M Ar & . 19S-2.
0 /qz� "014.
005uny
aurae o e C atinman
Aoe C unty Boand of
tC ommizzionetss