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12/13/1993 Agreement.r BAYSHORE MANOR A/K/A MONROE COUNTY HOME ADULT CONGREGATE LIVING FACILITY FOR THE ELDERLY A G R E E M E N T This agreement entered into this N day of DECAA4041t , 19 1.7 by and between the County of Monroe, State of Florida, hereinafter called "COUNTY" and 6D oA 400(rAe NRy , hereinafter called "RESIDENT", and (LO m PiNLe hereinafter called "RESPONSIBLE PARTY". W I T N E S S E T H: WHEREAS, RESIDENT desires to live in the County facility known as Bayshore Manor, and WHEREAS, COUNTY has reviewed RESIDENT'S application for admission to Bayshore Manor and has determined that RESIDENT is eligible for admission, now therefore, In consideration of the mutual covenants, promises and premises herein contained, the parties agree as follows: A. BAYSHORE MANOR: 1. Shall furnish room, board, linens and assistance with activities of daily living as may be required, based upon RESIDENT'S mental and/or physical limitations both at and subsequent to the time of admission. 2. Shall arrange for transportation of RESIDENT to his/her physician's office and/or arrange for RESIDENT'S transportation to hospital if such transportation is ordered by physician or if, in the opinion of the Director or his surrogate, RESIDENT'S condition so warrants. The RESPONSIBLE PARTY (as designated herein) will be immediately notified if RESIDENT requires hospitalization. 3. Shall make refunds on a per diem basis commensurate with the date of discharge from Bayshore Manor. Refunds will not be made for any days that personal belongings remain in RESIDENT'S room. Refunds will not be made as long as there are outstanding expenditures for services received by RESIDENT. 4. Shall, in the event of closure of the facility for any reason, make a pro -rated per diem refund as of the date of such closure. Such applicable refund will be made within SEVEN (7) DAYS of closure, in compliance with 1 Florida Statutes. 5. Shall notify RESIDENT and/or RESPONSIBLE PARTY in writing THIRTY (30) DAYS in advance of any rate change. 6. Shall maintain no affiliation with any religious organization, except to provide assistance to RESIDENT in contacting such organization upon RESIDENT'S request. 7. Subject to the availability of funds, shall pay for such medications as may be prescribed for RESIDENT by his/her physician, as well as necessary non-prescription medical supplies, provided that RESIDENT'S monthly rate under this agreement is less than maximum rate and RESIDENT has insufficient medical insurance to cover such expenses, or in the event that RESIDENT'S monthly rate under this agreement is the maximum rate but RESIDENT has neither sufficient additional funds nor sufficient medical insurance to pay for the above. 8. Shall provide to RESIDENT whose monthly rate is less than the maximum rate, or who is paying the maximum rate and has no additional funds, on a monthly basis, TWENTY ($20.00) DOLLARS for his/her personal use. Such monthly reimbursements will be skipped or reduced any month when full payment would result in RESIDENT having more than ONE HUNDRED ($100.00) DOLLARS in his/her possession; or any month that RESIDENT receives funds for personal use of up to TWENTY ($20.00) DOLLARS, from any source, such as OSS, etc., to the extent necessary to assure RESIDENT of at least TWENTY ($20.00) DOLLARS for personal use. 9. Other: EnPA 1_004144011%1 WILL i3L' AbmsTrrA Te iidYsNo4Z M4#d4 B. RESIDENT and/or RESPONSIBLE PARTY 1. Shall provide all clothing and personal effects as required by RESIDENT. 2. Shall pay the agreed upon monthly rate no later than the third day of each calendar month. 3. Shall comply with all requirements set forth in the application for admission. 4. Shall fully comply with all rules and regulations as now established by COUNTY or as may, in the future, be amended or established. 5. Shall make arrangements for RESIDENT'S immediate transfer to an alternative, appropriate facility upon certification by either a physician or the Director of Bayshore Manor that RESIDENT is no longer capable of meeting the requirements for residence in the facility. In the event that RESIDENT has no person or agency, whether RESPONSIBLE PARTY, next of kin or other person or agency appointed to act on RESIDENT"S behalf to represent him/her, Bayshore Manor shall assist RESIDENT in contacting an appropriate social service agency for placement. RESIDENT agrees to vacate the facility within SEVEN (7) DAYS after disqualification. 6. Shall, if RESIDENT is not paying the maximum rate, pay any increase in RESIDENT'S income (from any source) to COUNTY during his/her stay at Bayshore Manor, up to but not exceeding the maximum rate as may from time to time be adjusted by COUNTY. 7. Shall, if funds for medication expenditures become unavailable, make arrangements for payment of medication expenses which Bayshore Manor cannot pay or arrange for RESIDENT'S transfer to an alternative, appropriate facility. 8. Shall maintain on file with Bayshore Manor an up-to-date name, address and telephone number for RESPONSIBLE PARTY or next of kin. 9. Other ilffs)WALL PAATY 01" A110044 YbrA 94_T V*J.(1©g4#rY riR RU0X^ J AopjAmAa, 'Jit 0AyjAy1r Tw4c TdTA&. t)fr OF SArK�• inimiaLA -04otn vsw. Mr Fort A" of ,?Bracar1 w•ri�c�rro�ct u•JT�� D/h1Ai11N TO 1A$J TH40 Two HOAAR0 48200•a0) pdLL-4AJ- C. FINANCIAL RESPONSIBILITY RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY $ 7j,3.00 per month for use of COUNTY' S Bayshore Manor facility. Monthly payment shall be derived from the following sources: 1. Personal funds of RESIDENT 2. RESPONSIBLE PARTY will pay 3. Monthly income of RESIDENT: Social Security income Supplemental Security Income Railroad Retirement income Civil Service income V.A. Pension Other D. STANDARD ADMISSION WAIVER $ 7S"3-ov $ -Pr $ -H $ -8 $ -8 COUNTY shall continually exercise such reasonable care as to maintain the health and safety of RESIDENT. However, COUNTY does not provide any assurance or guarantee for RESIDENT'S health and safety and shall have no liability for same. COUNTY shall have no liability or responsibility for cash or other valuables which RESIDENT may, at any time, have in his/her possession on the 3 premises of Bayshore Manor. RESIDENT shall hold COUNTY harmless for any and all claims arising directly or indirectly from any negligent or intentional act of RESIDENT. E. RESIDENT PERSONAL CASH RESIDENT shall at no time have in his/her possession on the premises personal cash in excess of ONE HUNDRED ($100.00) F. MEDICAL AND DENTAL SERVICES COUNTY shall not be responsible for the payment of any medical, chiropractic, dental or hospital bill incurred by RESIDENT. Furthermore, COUNTY shall not be responsible for the payment of RESIDENT'S "over-the-counter" or prescription medications except as detailed in paragraph A-7, above. G. TERMINATION OF AGREEMENT In the event that RESIDENT vacates Bayshore Manor for more than FOURTEEN (14) consecutive days, except for hospitalization, this agreement shall automatically terminate, and RESIDENT or RESPONSIBLE PARTY shall remove all of RESIDENT'S personal property immediately. If property is not removed in a timely fashion, the parties agree that COUNTY is authorized to remove and dispose of such property after having made a reasonable effort to deliver it to RESIDENT or RESPONSIBLE PARTY, without success. In addition to the methods of terminating this agreement, detailed in Paragraphs B-5 and G, above, it may be terminated by RESIDENT upon written notice to COUNTY at any time. Additionally, COUNTY may terminate the agreement upon THIRTY (30) DAYS written notice to RESIDENT of RESPONSIBLE PARTY, certified mail, return receipt requested. H. DURATION OF AGREEMENT 4 Unless otherwise terminated, this agreement shall remain in full force and effect until such time as a new agreement is duly executed. I. AMENDMENTS TO AGREEMENT This agreement may be amended at any time subsequent to its execution by both parties, or their legal representatives, by the parties or their legal representatives signing and executing such an amendment. J. NOTICE Any notice required by this agreement to be made by either party shall be made as follows: BAYSHORE MANOR Name: 48Xitf E. 4,914 0J. ND Address:. ,CIoo Cos.& :CC O1� Vidy LdifrY, FL. 330y0 Phone: (3oQ 21y-Y446 RESIDENT/RESPONSIBLE PARTY Name: 64ORI ►A g09d Address: JOY SI RI JJ 1140E `rAruARa W PA2rf' . VL. MOO Phone: (303) 292^7617 Parties may substitute the above by proper notice. K. FLORIDA LAW Both parties shall at all times comply with the Laws of the State of Florida and Monroe County. Further, RESIDENT agrees that the proper jurisdiction and venue of any claims arising under this agreement shall be in Monroe County, Florida. 5 WITNESSES AS TO RESIDENT rLA-A Ix WITNESSES AS TO RESPONSIBLE PARTY DATE • DATE: i a _ APPROVED: SIGNATUR OF RESIDENT SIGNATURE OF RESPONSIBLE PARTY SIGNATURE OF DIRECTOR, BAYSHORE MANOR SIGNATURE OF EXECUTIVE DIRECTOR, MONROE COUNTY SOCIAL SERVICES DEPARTMENT SIGNATURE OF MONROE COUNTY ADMINISTRATOR APPROVED AS TO FO!`,R f AND vUFFlCl^By 0