12/01/1981 Agreementr /
BAY SHORE MANOR A/K/A
iiO::ROS COU:IT`I HO::E ADULT CO, ;GREG\TE
LIVI: G FACILITY FOR THE ELDERLY - LEVEL II
A G R E E 'M E N T
This Agreement entered into this 1st day of
December 19 81 by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Miriam V=1 lc, -
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:
A. BAY SHORE 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 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
B.
C.
TT;F D^Cj. E-T (err
1. To provide such" F rrsonal clothin',- =0
erEects as neeced or ,,wired by the
Resident.
2. To pay the monthly rate agreed upon any:
such charges as deterT^ined by the :Monroe
County Dome to be necessary for the
operation of the home.
3. That, upon certification by a physician
or the A.rministratcr 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 ir^mediate
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
place_-ent. Arplicant agrees to vacate
the facility within forty-eight (48)
hours after Oisaualification.
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: To be responsible for all
hospital and physician costs.
FINANCIAL ARPANGFi'[FNTS
The Resident and/or responsible party agrees to
pay to the County $ 665.00
rent for use of the facilities.
, per month as
Payment will be from the following sources:
1. Personal funds of Resident $ 665.00
2. Responsible party will pay $
3. Unearned income of Resident
will pay:
Social Securitv
M
Civil Service Annuity $
VA Pension $
Other $
The County thro'_.,;h lis r.711D10-I('es 11as a(-, reed to
exercise such reasonable care toward the ?esi(�ent 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 Ma.narement of this home will not be respon-
sible for any valuables or Toney left in the tDossession of
this person while he or she is a resident of this home.
E. ITFRMINATION
If Resident is absent from the home in excess of
fourteen (14) continuous days, such absence shall automa-
tically terminate this Agree -Tent and the Resident shall
re -move 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
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. DURA_TION OF AGRFF'AF''T
Either party may terminate this agreement on five
(5) days written notice. Other;,7ise, it will remain in
effect until a different aaree_ment is executed. However,
this does not mean that a Resident wil b2 forced to remain
in the facility against his/her will for any length of time.
,.
Signature of Resident
Witnesses as to Resident
Witnesses as to
Responsible Party
Signature of Responsible
Party
DATF J14-. l Cz,
APPP.OVED:
, � 1"JImij
Signature of Representative
of Monroe County 110me aka
Bay Shore Manor
Signature of Executive
Director, Monroe County
Social Services
_ Sia ture of County
A(f,_inistrator _
THIS IS TO CERTIFY THAT THIS ADMISSION AGPFFMENT AS
APPROVED BY THE COUiiTY HOME AND THE COUNTY 7J—VINISTPATOR
WAS P.ATIFIFD BY THE MONROF COUNTY BOARD OF COI-NTY
COlL`•lISSIONFRS AT THEIP M7TTING HELD ON THE %�,DA_Y
OF_0(d,4 lq�.
�C- �'
- .,Jlo SiQR&ture of the Chai , .an
Monroe County Board of
County Commissioners