07/12/1991 Agreementc= - BAYSHORE MANOR
o A/K/A MONROE COUNTY HOME
ADULT CONGREGATE LIVING FACILITY
FOR THE ELDERLY - LEVEL II
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A G R E E M E N T
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This agreement entered into this 12th day of
July , 19 91, by and between the County of Monroe,
State of Florida, hereinafter called "County" and Paul J.
Holm hereinafter called "Resident", and
Joyce Holm hereinafter called "Responsible
Party."
WITNESSETH:
WHEREAS, the'resident desires to use the facility of the
county known as the Monroe County Home, a/k/a Bayshore Manor, and
WHEREAS, the County has reviewed the application of the resi-
dent 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 premis-
es herein contained, the parties agree as follows:
A. BAYSHORE MANOR
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 the resident's choice when
ordered by the attending physician or the health
of the resident requires same, and 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 discharge 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. In the event of closure of the facility for any
reason, a pro -rated per diem refund shall be made in
accord with date of closure within seven (7) days.
5. Residents will be notified in writing thirty (30)
days in advance of any basic rate change.
6. Bayshore Manor is not affiliated with any religious
organization.
7. Other:
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 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, 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 have to make
arrangements for the immediate transfer to an
appropriate facility. In the event a resident
has no person to represent him/her, this
facility shall assist resident in contracting
an appropriate Social Service Agency for place-
ment. Applicant agrees to vacate the facility
within forty-eight (48) hours after disquali-
fidation.
4. To comply with all requirements as set forth
in the application made by the resident.
5. To comply with all rules and regulations esta-
blished by the County for operation and control
of said home.
6. Agrees, if not paying the maximum rate, to pay
any increase in income during the course of
residency, up to the maximum rate. The maximum
rate as established October 1, 1985, is $1,195.00
per month.
7. Individual monthly rents not to exceed the maximum
rate, will be established by evaluation of the
applicant's income, asset, resources and need.
8. Other: Will pay Blue Cross/Blue Shield and Medicare
premiums and deductibles and any other medical costs not
covered by insurance, including all medications.
C. FINANCIAL ARRANGEMENTS
The resident and/or responsible party agrees to pay
County $ 1,195.00 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 Security
Civil Service Annuity
V.A. Pension
Other
$ N/A
$ 1,195.00
$ N/A
$ N/A
$ N/A
$ N/A
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D. STANDARD ADMISSION WAIVER
The County, through its employees, has agreed to exercise
such reasonable care toward the resident as bis 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 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 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. 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 representatives at the time of the rendering of service.
G. DURATION OF AGREEMENT
Either party may terminate this agreement on thirty (30) 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. This agreement may be amend-
ed by written and executed approval of such amendment by both
parties or their representatives at the time thee en .
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SIGNATURE OF RESIDENT
WITSSES AS TO RESIDENT
S� AT RE OF RESPONSIBLE PARTY
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WITNE,SfE'S KS TO RESPONSIBLE PARTY
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DATE
APPROVED:
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Signature of Representative
of Monroe County Home a/k/a
Bayshore Manor
Signature of Executive
Director - Monroe County
Social Services
Administrator
IS91
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 Commissioners at their meeting held
on the 28th day of August lg 91
(SEAL)
ATTEST: DANNY L. KOLHAGE, CLERK
By �•��•
DepV Clerk
Signature of the Chairman
Monroe County Board of
County Commissioners
APPROVED AS TO FORM
...,AND LWAL SUFFICIENCY
Attorney Unite f
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