12/01/1981 AgreementBAY SHORE MANOR A/K/A
iIONRO COt;NT`i H0:•1E. ADULT COXREG ATE
LIVI:;G FACILITY FOR THE: ELDERLY - LEVEL II
AGREEMENT
This Agreement entered into this 1st day of
Decmeber 19 81 by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Anna L. Knowles
hereinafter called "Resident", and
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:
. • • ar
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: To pay medicare deductible8O�balance of
hospital services after medicare for the first
14 days. To pay RO% of hal ance after medicare
payment for physicians services.
5. Other: To reimburse resident $ 10.00 per
Bill, "ILiqlaw-ce
1. To nrovide suc^ r(,rso: _,_l clothinr; an0
efFects as neec:.(J osirec by
Resident.
2. To pay the monthly rate agreed upon and
such charges as deter_minec by the Yonroe
County Home to be necessary_ for the
operation of the home.
3. That, upon certification by a physician
or the Pdministrator 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 arrancements 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
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 Ppplication 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:
C. FINANCIAL RRPANGFMFNTS
The Resident and/or responsible party agrees to
pay to the County $ �91.30 , 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 Securit;; $ 381.30
Civil Service Annuity $
VA Pension $
Other
R
ThC: Count%- throUCTn its Cmplo' yes has a<Trcnri to
exercise such reasonable care toward the Resic'.ent as his or
her known condition may require, however, this hole is in no
sense an insurer of his or her safety or welfare and assumes
no liability as such.
The Manacement of this home will not he 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. TFR^1TNA7TnN
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
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 Countv 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. DUPATIOTT OF AGRFF,IFNT
Either party may terminate this agreement on five
(5) days written notice. Cather;aise, it will remain in
effect until a different agreement is executed. However,
this does not mean that a Resident wil be forced to remain
in the facility against his/her will for any length of time.
- - �R'e"
1^7itnesses as to Resident
Signature of Resident
ona re of Responsible
t•7i nesses as to
P o.rtv
Responsible Party
DATF '(/� /c�Z / �dol�l
APPROVED -j�4PQ
)az�lzv"�-j
Signature of Pep resentat ive
of Monroe County Home aka
Bay Shore Manor
Signature of Executive
Director, Monroe County
Social Services
Sim ture of County
Adm'nistrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGRFFPIENT AS
APPROVED BY THE COUNTY HOME AND THE COUNTY ADtAINISTPATOR
WAS PATIFIFD BY THE 1IONROE COUNTY BOARD OF COUNTY
CO -M-ISSIONERS AT THEIP. MEETING HELD ON THE -DAY
4z .00---,
4-1
Sig ature of the Chairman
Monroe County Board of
County Commissioners