01/01/1984 AgreementBAYSHORE MANOR A/K/A
MONROE COUNTY HOME, ADULT CONGREGATE
LIVING FACILITY FOR THE ELDERLY - LEVEL II
AMENDED
A G R E E M E N T
This Agreement entered into this 1st
January
day of
19 84 , by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Ellen Lopez
hereinafter called "Resident", and N/A
0
, hereinafter called "Responsible Party",
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, a/k/a/ Bayshore
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. 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 Resident's
choice, when ordered by the attending
physician or the health of the Resident
requires same, the 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 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. Other: To pay medicare deductible 80% of
balance after medicare for 1st 14 days of hospital
care 80% of balance after medicare for physician
services.
S. Other: To reimburse resident ten ($10.00) dollars per month
for personal spending money.
- C)�a A
Fo� _-------- ----- - ----
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
be notified and the Resident 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 regulations
established 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.
7. Other: NONE
C. FINANCIAL ARRANGEMENTS
The -Resident and/or Responsible Party agree(s) to
pay to the County $ 261.00
of the facilities.
, per month as rent for use
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
$ 261.00
S
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 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 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.
Witnesses as to
Responsible Party
a�&' )�n� -
Signature of Resident
Signature of Responsible
Party
r
DATE:
APPROVED: /2 L/�,ZP3
,lgriature o Representative
of Monroe ounty Home a/k/a/
Bayshore Manor
Signature of Executive
Director - Monroe County
Social Services
Sig ature of County
Administrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGREEMENT AS APPROVED
BY THE COUNTY HOME AND THE COUNTY ADMINISTRATOR WAS RATIFIED
BY THE MONROE COUNTY BOARDPF COUNTY COMMISSIONERS AT THEIR
MEETING HELD ON THE %� DAY OF
19Z� .
Signature of —the Chairman
Monroe County Board of
County Commissioners