09/11/1981MONROE COUNTY HOME, ADULT CONGREGRATE
LIVING FACILITY FOR THE ELDERLY - LEVEL II
A G R E E M E N T
This Agreement entered into this 11th day of
September , 19 81
, by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Mary B. Herrick
hereinafter called "Resident", and Govan x. Herrick
Party"
, hereinafter called "Responsible
W I T N E S S E T H:
BBBB WHEREAS, the Resident desires to use the facilities
of the County known as The Monroe County Home, 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. THE MONROE COUNTY HOME
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: None
5. Other: None
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.`
B. THE RFSIDENT 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 determined by the Monroe
County Home to be necessary for the
operation of the home.
3. That, upon certification by a physician
or the Administrator 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 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. Other: To be responsible for all medical and
hospital costs.
C. FINANCIAL ARRANGEMENTS
The Resident and/or responsible party agrees to
pay to the County $ 410.00
rent for use of the facilities.
, per month as
Payment will be fromthe following sources:
1. Personal funds of Resident $ 21.60
2. Responsible party will pay $
3. Unearned income of Resident
will pay:
Social Security $ 388.40
Civil Service Annuity $
VA Pension $
Other $
r
D. STANDARD ADMISSION WAIVER:
The County through its employees has agreed to
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 Management 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. TERMINATION
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. MEDICA.L 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. DURATION OF AGRFFSAFNT
Fither party may terminate this agreement on five
(5) days written notice. Otherwise, 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.
wC �
Witr}.ez.,ses as to R ident
Witnesses as to
Responsible Party
Signa re of Resident
Signature of Responsible
Partv
DATE_ t7l &/
APPROVED:
- t -� I-
agnature of Representative
f Monroe County Home
Signature of Executive
Director, Monroe County
Social Services
Sfg,hature of County
Administrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGREPMENT AS
APPROVED BY THE COUNTY HOME AND THE COUNTY Arl1.4'INISTR1aTOR
WAS RATIFIED BY THE MONROE COUNTY BOARD OF COUNTY
COMMISSIONERS AT THEIR. MEETING HELD ON THE DAY
OF 19
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Q
gre of the C irman
A6niqnat
roe County Boa of
County Commissioners