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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 t4, 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.