03/11/1992BAYSHORE MANOR
A/ K/ A MONROE COUNTY HOME F! L F( i Y ^ r 0 R n
ADULT CONGREGATE LIVING FACILITY
FOR THE ELDERLY - LEVEL 11 ,-, 1 ; .
A G R E E M E N T
This agreement entered into this 13th day of
February , 19 92, by and between the County of Monroe,
State of Florida, hereinafter called "County" and
Charles '.'Jerzy" Pinder, hereinafter called "Resident", and
Donald Pinder hereinafter called "Responsible
Party."
WITNESSETH:
WHEREAS, the resident desires to use the facility of the
county known as the Monroe County Home, a/k/a Bayshore Manor, and
WHEREAS, the County has reviewed the application of the resi-
dent 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 premis-
es 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 the resident's choice when
ordered by the attending physician or the health
of the resident requires same, and to immediately
notify any responsible party (as designated herein)
of such transfer.
3. To make refunds on a per diem basis in accord
with date of discharge from 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. In the event of closure of the facility for any
reason, a pro -rated per diem refund shall be made in
accord with date of closure within seven (7) days.
5. Residents will be notified in writing thirty (30)
days in advance of any basic rate change.
6. Bayshore Manor is not affiliated with any religious
organization.
7. Other: To reimburse resident TEN DOLLARS ($10.00) per
month for personal spending money - Starting March 1992.
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 have to make
arrangements for the immediate transfer to an
appropriate facility. In the event a resident
has no person to represent him/her, this
facility shall assist resident in contracting
an appropriate Social Service Agency for place-
ment. Applicant agrees to vacate the facility
within forty-eight (48) hours after disquali-
fication.
4. To comply with all requirements as set forth
in the application made by the resident.
5. To comply with all rules and regulations esta-
blished 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. The maximum
rate as established October 1, 1985, is $1,195.00
per month.
7. Individual monthly rents not to exceed the maximum
rate, will be established by evaluation of the
applicant's income, asset, resources and need.
8. Other:
C. FINANCIAL ARRANGEMENTS
The resident and/or responsible party agrees to pay
County $ 524.00 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 Security
Civil Service Annuity
V.A. Pension
Other
$ 524.00
2
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 thirty (30) 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. This agreement may be amend-
ed by written and executed approval of such amendment by both
parties or their representatives at the time of the amendment.
(L_�30'4- aLL-i -)
SIGNATURE OF RESIDENT
WITNESSES AS TO RESID T
r / SIGNATURE OF RESPONSIBLE PARTY
WITNESSES AS TO RESPONSIBIM PARTY
3
DATE: LAt. 13_ /912—
APPROVED:
Signatfir of R presentative
of Monroe Cou ty Home a/k/a
Bayshore Manor
Signature of Executive
Director - Monroe County
Social Services
Administrator
199le
This is to certify that this Admission Agreement as approved by
the County Home and the County Administrator was ratified by the
Monroe County Board of Co ty Commissioners at their meeting held
on the_ day of re- 4 , 19" -
(SEAL)
ATTEST: DANNY L. KOLHAGE, CLERK
By
Deputy erk
0. -
w
Signature of the Chairman
Monroe County Board of
County Commissioners
AS FORM
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Sll 1CIE Y
Sy
Mornay's Ofte
Date L 2.6 --Cf Z
4
BAYSHORE MANOR
ADMISSION, RETENTION, DISCHARGE AND REFUND POLICY
I. ADMISSION POLICY
To meet the statutory requirements for admission to Bayshore
Manor, a State licensed Adult Congregate Living Facility, the
following criteria must be met at the time of admission, based on
the medical examination report and the following factors as
determined by the Director of Bayshore Manor:
1. The applicant:
a. Does not require more than personal supervision of or
assistance with ambulation, grooming, eating, and dressing:
b. Does not require more than personal supervision of or
assistance with self-administered medication: or
c. If the resident requires administration of medication, the
resident or the responsible party contracts with a third party to
provide this service.
d. Is able to participate in social or leisure activities.
e. Is not incontinent of bladder or bowel, unless the resident
only requires assistance with personal hygiene or is able to
contract with a third party to provide this care.
f. Has not been adjudicated incompetent, or, if so, has a
legal guardian who is able to make decisions on his behalf.
g. Is non-violent, or, if violent, is controllable by
medication as determined by a physician.
h. Is free from apparent signs and symptoms of communicable
disease which is likely to be transmitted to other residents or
staff.
i. Is in sufficient health so as not to require licensed
professional care on a 24-hour basis with the exception of
administration of medication.
j. Is capable of self-preservation in an emergency situation
involving the immediate evacuation of the facility, with
assistance from staff.
II. RETENTION POLICY
The Director of Bayshore Manor is responsible for determining
the appropriateness of admission of an applicant and for
determining the continued appropriateness of residence of a
resident in the facility. Criteria for continued residency shall
be the same as admission criteria.
III. DISCHARGE POLICY
A resident of Bayshore Manor may be discharged and his/her
admission contract terminated:
a. By the resident and/or responsible party, at any time.
b. By Bayshore Manor upon THIRTY (30) DAYS written notice to
the resident and/or responsible party, certified mail, return
receipt requested.
C. If the resident vacates Bayshore Manor for more than
FOURTEEN (14) CONSECUTIVE DAYS, except for hospitalization of the
resident.
d. Upon certification by either a physician or the Director of
Bayshore Manor that the resident is no longer capable of
meeting the requirements for residence in the facility, in which
case the resident or responsible party will be required to vacate
the facility within SEVEN (7) DAYS after disqualification.
e. If, in the judgement of the Director of Bayshore Manor,
the resident manifests such chronic behavior as to pose a
physical or mental danger to himself/herself or others, or who
manifests such chronic behavior as to interfere with the care and
comfort of other residents.
IV. REFUND POLICY
a. A pro -rated, per diem refund will be made to the resident
or responsible party commensurate with the date of discharge from
Bayshore Manor, except that such refund will be reduced to the
extent of any outstanding expenditures for services received by
the resident as well as to the extent of any damage to the
facility as may have been caused by the resident, above and
beyond reasonable wear and tear. Such a refund will be made
within FORTY-FIVE (45) DAYS of discharge.
b. In the event of closure of the facility for any reason, a
pro -rated, per diem refund will be made to the resident or
responsible party as of the date of closure; and such refund will
be made within SEVEN (7) DAYS of closure.