04/07/1987i
AMENDED AGREEMENT Match 13, 1987
BAY 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
This agteement entered .into tW 13th
day of Match
198_, by and between the County of Montoe, State of
F.totcida, heAeinajteA caned "County", and Etecta Schaj j et Gtii, jin
heAe i.najteA cat ted "Resident", and
None
hene%najteA catted "Ra po"ib.te Patty",
WI TN ESS ETH:
WHEREAS, the Resident desite/s to ups e the jacit ity of the County
known as the Montoe County Home, a/k/a Bay Shote Manot and,
WHEREAS, the County has Reviewed the appti.cati.on of the taident joA
adm.izzion to the Montoe County Home and hat6 detetcm.ined that the Resident .us
eQ,igib.te jot adm. 6zion to .said home, now, theAe6ote,
In con�sidetati.on of the mutual covenants, ptcomi,6e,6 and ptemizes
heAe%n contained, the paxtiet6 agtee as jot ttom :
A. BAY SHORE MANOR
1. To juAnizh Loom, board, ti.nenz, ptesctc.i.bed medicines
and genetutt petusona.t carte.
2. To atvca.ng e joA the tAa" j etc of the Aes.Ldent to the
hozpcta2. of the Aesident',s choice when otdeAed by the
attending phy.6ician oA the he.aPth of the taident
tequ,it m same, and to immedcatety notij y any
tapons.ib.te panty (as designated heAei.n) of ouch tAandjeA.
3. To make Aejundts on a pets diem bazis in accord with date
of di6chaAge jtom the home. Rejunds cannot be made a6
.tong as pex onat betongingls Remain in the Aes.ident'z
Loom. Rejunds cannot be made as .tong as thete ate
outstanding expendctu.Aez jot seAvices teceived by the
te,sident.
• 4. In the event of etosute of the jacit ty dot any Aeason,
a pAo-bated peA diem tejund shaft be made in accord
with date of cto/sute.
5. OtheA: To Aeimbuts e Ae.6.ident ten ($1 0) dot Cats
pet month jot peA,sona.t spending -money.
6. To pay Med%caAe deductib.te 80 % of baZaaciq g( otr
MedicaAe jot j,urst 14 days of hozp-ctat cote, 80% of
batance ajteA Medicate jot phys.ician�s zetcv.ices.
B. THE RESIDENT OR RESPONSIBLE PARTY
1. To provide such petusonat ctoth,ing and e66ect�s cvs
needed on det,,ited by the taident.
2. To pay the monthtY rate agreed upon and zuch
chaAges as determined by the Monroe County Home
to be neceszaAy bon the operation o6 the home.
3. That, upon ceAti6ication by a phyzici.an on the
adm-i.n usttcatoA o6 the home, the neisident is no
ZongeA capable o6 meeting the nequiAement6 6oA
occupancy in t iz baciti ty, the tezident, next o6
kin, .begat AepAesentative oA agency acting on the
Aesident',s behat6, w.iU have to make aAAangements
boA the immediate tAansjetc to an appnopAi.ate /6acluity.
In the event a te/sident has no pens on to tepne�s ent
him/hen, tW 6acc ty .shaU assist kesident to
contacting an appnoptiate Soc%.a.t SeAvice Agency �oA
p.tacement. Appticant agneez to vacate the �acct ity
within 6onty- eight (48) houu a�teA d s quatc 6ication.
4. To comp.ty with at,t Aequ.itcements as .6et b oAth in the
appt i.cation made by the Ae�s.ident.
5. To comply w,cth. aU �u,ta and Aegutati.onz estab.?,Lshed
by the County 6oA operation and contno.t ob zaid home.
6. AgAees, i6 not paying the maximum Rate, to pay
inctcea,se in income duni.ng the course ob Auidency,
up to the maximum Rate.
7. with eA:
C. FINANCIAL ARRANGEMENTS
The Ae�sident and/oA ne6pons.ib.te panty agAee,6 to pay to the
County $ 333.00 peA month as Aent Am use o� the 6accrP,itie6.
PAYMENT WILL BE FROM THE FOLLOWING SOURCES:
1. Pmona.t 6unds ob Ae/sident
2. Rezpon ib.te panty wilt pay
3. Unearned .income o6 ALa ident
w,t2t pay:
Soc%.a.t Secuncty
Civit SeAv ice Annuity
V. A. Pension
OtheA
$ 333.00
N
D. STANDARD ADMISSION WAIVER
The County, through its emptoyea , has agreed to exercise such
neaaonabf.e cane towatcd the nLuident ate h.us on hen known condition may Aequ-iAe.
However, thus home iz .in no sense an .in�sunen ob his on hen sa6ety oA wetatce
and cvs,sumes no Ziab.c city at6 Such.
The management 06 t►iz home wilt not be tespom ibte �oA any
vatuabtu oA money .2e6t in the pozzession ob thiz petuson white he oA she is
a Aa ident o4 thi.6 home.
B. TERMINATION
I� ALa ident is absent 6,tom the home in excess o6 6outcteen (14)
continuou,s days, such absence zha.Pt automaticatty teAm.inate thus agreement
and the Aes ident shatt remove att o6 his oA hen pAopenty or beeongings
.cmmedcate2y. 16 Au ident 6a.it,6 to remove same, the tes.ident doe's hereby
authoAize the County to remove said pnopetcty on beeonginp and detiveA tame
to tuponz ibte patrty.
F. MEDICAL SERVICES
The patcti.ez agree that Monroe County shah not be Auponzibte 6oA
on assume any tuponz ibit ty 6oA payment o6 any medicae on hospitat zenvd.ce6
untaz z pec i6.icatt y agreed to by the paAti.e6 oA the.itc Aepnez enta tiv es at the
time ob the tendetrin.g o5 service.
G. DURATION OF AGREEMENT
EitheA parity may teAminate this agreement on thi ty (30) day.6
wtc,itten notice. Othe avis e, it w.i Pt Aema.in in e� 4 ect untu2 a di6 6 event
agreement .us executed. However, this does not mean that a to ident wilt be
forced to remain in the jacit ty against his/her w.itt boA any .length o4 time.
STG4TTURE OF RESIePT
WI SES T RESIDE T
WITNESSES AS TO RESPONSIBLE P RTV
SIGNATURE OF RESPONSIBLE P RTV
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APPROVED:1-2
Sig na une Repness entativ e
ob Monnoe -unty Home a/k/a
Bay Shone Manors
'7
` - ,�
S.ignatune o6 Executive
D.inecxon--Monnoe County
Sociat SuLv ices
S-in atune a County
Administt Latan
This is to cent.ij y that this Admission Agreement as appnov ed by
the County Home and the County Adm.inisttLatan was nati6 ied by the
Monnoe County Board o6 County Commizz ioneu at the -in meeting
held on the th day o{ �_� , 1987
Stig nat A e o6 the c hatinm
Monnoe County Boand of
County Comm.izz ionms
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