12/01/1981v
BAY SHORE MANOR A/K/A
i:ONP.OF COL dTY H0:•iE , ADULT CO:;GREG ��TE
LIVING FACILITY FOR THE ELDERLY — LE, EL II
December
A G R E E M E N T
This Agreement entered into this lst
day of
, 19 81 , by and between the County of
Monroe, State of Florida, hereinafter called "County", and
Beverly A. Morri
hereinafter called "Resident", and
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, 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 m.
to said home, now, therefore,
IN CONSIDERATION of the mutual covenants, promises
and premises herein contained, the parties agree as follows:
.• I u•►•:
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 deductih1e80balance
of hospital services after medicare fer first
14 days. To pay 80% of balance after medicare
payment for physicans services.
5. Other: To reimburse resident $10.00 per
month for personal spending funds.
1. To provic'e stir'.: rersonal clothing: an0
of fects as nee( c,di 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 A.eministrator of the F:ome, 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 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 disuualification.
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: None
C. FINANCIAL ARPANGFIMFNTS
The Resident and/or responsible party agrees to
pay to the County $ 13/ 0,00 , per month as
rent for use of the facilities.
Payment will be frog,, the following sources:
1.
Personal funds of
Resident
$
2.
Responsible party
will pay
$ �� , '50
3.
Unearned income of
Resident
will pay:
Social Security $ 233,50
Civil Service :,�.nnuity $
VA Pension $
Other 8
Th .:� Count,,- thrcu,.h its emr_)1o•,;ees has arr_eed 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 Manac*ement of this home will not be respon-
sible for any valuables or money left in the iDossession of
this person while he or she is a resident of this hom.e.
E. TFP,n°IINATION
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
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
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. DUPATION OF AGR^z-'A'_r jT
Either party may terminate this agreement on five
(5) days written notice. Othenaise, 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.
Line
Witnesses as to
Responsible Party
SignaturVof Resident
Pasty
sible
DATF . /, I gd q-_
APPROVED:,�/p/v .1
Signature of`Pepresentative
of Monroe County Home aka
Bay Shore Manor
Sig ature of Fxecutive
Director_, Monroe County
Social Services
Si, ature of County
Administrator
THIS IS TO CERTIFY THAT THIS ADMISSION AGREPMENT AS
APPROVED BY THE COUNTY HOME ATJD THE COUNTY ADr^Ir'ISTPZ\TOR
WAS RATIFIFD BY THF MONROF COUNTY BOARD OF COUNTY
COMMIS IOr�FRS _ T THEIP- MPFTIT;G HELD ON THE DRY
OF 19.
Signature of the Chai ,.an
Monroe County Board of.
County Commissioners