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03/28/1990 Agreement1 BAYSHORE MANOR A/K/A MONROE COUNTY HOME ADULT CONGREGATE LIVING FACILITY FOR THE ELDERLY - LEVEL II A G R E E M E N T .01 This agreement entered into this day of /Z,� , 19 90, by and between the County of Monroe, State of Florida, hereinafter called "County" and Russell Michael Russell Party." WITNESSETH• Joseph A. , hereinafter called "Resident", and , hereinafter called "Responsible 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 pay medicare deductible, 80% of balance after medicare for 1st fourteen days of hospital care, 80% of balance after medicare for physician services, and prescription medication costs. To reimburse resident 10.00 per month for personal spending money. EcLtIVE� r E B 2 1 199 ,-TV ADMINISTRO 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: N/A C. FINANCIAL ARRANGEMENTS The resident and/or responsible party agrees to pay County $ 483.00 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 $ N/A $ N/A $483.00 $ N/A $ N/A $ N/A 2 I 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. j_- MV, A 4 SIGNATURE OF RESIDENT WITNESSES A8 TO RESIDENT � r _MtNATURVOF RESPONSIBLE PARTY WITNESSES AS TO RESPONSIBLE PARTY 3 DATE: APPROVED: Signa ure of Rep esentative of Monroe County Home a/k/a BayshoMe r �C7 V Signature of Executive Director - Monroe County Social Services 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 Board of Cou ty Commissioners at their meeting held on theOPW day of Avr." , 19jpd . ATTEST:DANNY L. K©LHAGE, Clerk 4e2,j,,, C;rk Signature of the Chairman Monroe County Board of County Commissioners APPROVED AS rO FORM AND LEGA! By C_ i t4Atrory'S 4