01/12/1993a
RAYSHORE MANOR
A/K/A MONROE COUNTY HOME
ADULT CONGREGATE LIVING FACILITY
FOR THE ELDERLY
A G R E E M E N T
This agreement entered into this 12tlday of JANUARY
19_2L,
,
by and between the
County of Monroe, State of Florida,;
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hereinafter called
"COUNTY" and GRACE SPARKS
hereinafter called
"RESIDENT", and RI CHARD A. HEYMAN
hereinafter called
"RESPONSIBLE PARTY".
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W I T N E S S E T H:
WHEREAS, RESIDENT desires to live in the County facility known as
Bayshore Manor, and
WHEREAS, COUNTY has reviewed RESIDENT'S application for admission
to Bayshore Manor and has determined that RESIDENT is eligible
for admission, now therefore,
In consideration of the mutual covenants, promises and premises
herein contained, the parties agree as follows:
A. BAYSHORE MANOR:
1. Shall furnish room, board, linens and assistance with
activities of daily living as may be required, based
upon RESIDENT'S mental and/or physical limitations both
at and subsequent to the time of admission.
2. Shall arrange for transportation of RESIDENT to his/her
physician's office and/or arrange for RESIDENT'S
transportation to hospital if such transportation is
ordered by physician or if, in the opinion of the
Director or his surrogate, RESIDENT'_,$ condition so
warrants. The RESPONSIBLE PARTY (as designated herein)
will be immediately notified if RESIDENT requires
hospitalization.
3. Shall make refunds on a per diem basis
commensurate with the date of discharge from Bayshore
Manor. Refunds will not be made for any days that
personal belongings remain in RESIDENT'S room.
Refunds will not be made as long as there are
outstanding expenditures for services received by
RESIDENT.
4. Shall, in the event of closure of the facility for any
reason, make a pro -rated per diem refund as of the date
of such closure. Such applicable refund will be made
within SEVEN (7) DAYS of closure, in compliance with
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Florida Statutes.
5. Shall notify RESIDENT and/or RESPONSIBLE PARTY in
writing THIRTY (30) DAYS in advance of any rate change.
6. Shall maintain no affiliation with any religious
organization, except to provide assistance to RESIDENT
in contacting such organization upon RESIDENT'S request.
7. Shall pay for such medications as may be prescribed for
RESIDENT by his/her physician, as well as necessary
non-prescription medical supplies, provided that
RESIDENT'S monthly rate under this agreement is less than
maximum rate and RESIDENT has insufficient medical
insurance to cover such expenses, or in the event that
RESIDENT'S monthly rate under this agreement is the
maximum rate but RESIDENT has neither sufficient
additional funds nor sufficient medical insurance to pay
for the above.
8. Shall provide to RESIDENT whose monthly rate is less than
the maximum rate, or who is paying the maximum rate and
has no additional funds, on a monthly basis, TWENTY
($20.00) DOLLARS for his/her personal use.
Such monthly reimbursements will be skipped or reduced
any month when full payment would result in RESIDENT
having more than ONE HUNDRED ($100.00) DOLLARS in
his/her possession; or any month that RESIDENT receives
funds for personal use of up to TWENTY ($20.00) DOLLARS,
from any source, such as OSS, etc., to the extent
necessary to assure RESIDENT of at least TWENTY ($20.00)
DOLLARS for personal use.
9. Other• N/A
B. RESIDENT and/or RESPONSIBLE PARTY
1. Shall provide all clothing and personal effects as
required by RESIDENT.
2. Shall pay the agreed upon monthly rate no later than the
third day of each calendar month.
3. Shall comply with all requirements set forth in
the application for admission.
4. Shall fully comply with all rules and regulations as
now established by CQUNTY or as may, in the
future, be amended or.established.
5. Shall make arrangements for RESIDENT'S immediate
transfer to an alternative, appropriate facility upon
certification by either a physician or the Director of
Bayshore Manor that RESIDENT is no longer capable of
meeting the requirements for residence in the facility.
In the event that RESIDENT has no person or agency,
whether RESPONSIBLE PARTY, next of kin or other person
or agency appointed to act on RESIDENT"S behalf to
represent him/her, Bayshore Manor shall assist RESIDENT
in contacting an appropriate social service agency for
placement. RESIDENT agrees to vacate the facility
within SEVEN (7) DAYS after disqualification.
6. Shall, if RESIDENT is not paying the maximum rate, pay
any increase in RESIDENT'S income (from any source) to
COUNTY during his/her stay at Bayshore Manor, up to but
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not exceeding the maximum rate as may from time to time
be adjusted by COUNTY.
7. Shall maintain on file with Bayshore Manor an up-to-date
name, address and telephone number for RESPONSIBLE PARTY
or next of kin.
8. Other: Shall maintain in full force andeffect- any and all
health insurance in effect as of the da�z and rate
first above written, while in rest denr.a at Rawshore
Manor.
C. FINANCIAL RESPONSIBILITY
RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY
$1690.00 per month for use of COUNTY IS Bayshore Manor
facility.
Monthly payment shall be derived from the following sources:
1. Personal funds of RESIDENT $ 1690.00
2. RESPONSIBLE PARTY will pay
3. Monthly income of RESIDENT:
Social Security income
Supplemental Security Income
Railroad Retirement income
Civil Service income
V.A. Pension
Other
D. STANDARD ADMISSION WAIVER
$ -0-
$ N/A
$ N/A
$ N/A
$ N/A
$ N/A
$ N/A
COUNTY shall continually exercise such reasonable care as to
maintain the health and safety of RESIDENT. However, COUNTY does
not provide any assurance or guarantee for RESIDENT'S health and
safety and shall have no liability for same. COUNTY shall have
no liability or responsibility for cash or other valuables which
RESIDENT may, at any time, have in his/her possession on the
premises of Bayshore Manor. RESIDENT shall hold COUNTY
harmless for any and all claims arising directly or indirectly
from any negligent or intentional act of RESIDENT.
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E. RESIDENT PERSONAL CASH
RESIDENT shall at no time have in his/her possession on the
premises personal cash in excess of ONE HUNDRED ($100.00)
DOLLARS.
F. MEDICAL AND DENTAL SERVICES
COUNTY shall not be responsible for the payment of any medical,
chiropractic, dental or hospital bill incurred by RESIDENT.
Furthermore, COUNTY shall not be responsible for the payment of
RESIDENT'S "over-the-counter" or prescription medications except
as detailed in paragraph A-7, above.
G. TERMINATION OF AGREEMENT
In the event that RESIDENT vacates Bayshore Manor for more than
FOURTEEN (14) consecutive days, except for hospitalization, this
agreement shallautomatically terminate, and RESIDENT or
RESPONSIBLE PARTY shall remove all of RESIDENT'S personal
property immediately. If property is not removed in a timely
fashion, the parties agree that COUNTY is authorized to remove
and dispose of such property after having made a reasonable
effort to deliver it to RESIDENT or RESPONSIBLE PARTY, without
success. In addition to the methods of terminating this
agreement, detailed in Paragraphs B-5 and G, above, it may be
terminated by RESIDENT upon written notice to COUNTY at any
time. Additionally, COUNTY may terminate the agreement upon
THIRTY (30) DAYS written notice to RESIDENT of RESPONSIBLE PARTY,
certified mail, return receipt requested.
H. DURATION OF AGREEMENT
Unless otherwise terminated, this agreement shall remain in full
force and effect until such time as a new agreement is duly
executed.
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T. AMENDMENTS TO AGREEMENT
This agreement may be amended at any time subsequent to its
execution by both parties, or their legal representatives, by the
parties or their legal representatives signing and executing
such an amendment.
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J. NOTICE
Any notice required by this agreement to be made by either party
shall be made as follows:
BAYSHORE MANOR
Name: ROBERT E. LAZARUS, M.D.
Address: 5200 COLLEGE ROAD
KEY WEST, FLA. 33040
Phone: (305)294-4966
RESIDENT/RESPONSIBLE PARTY
Name :
Address:,?g2^ a
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Phone: •+?9 y - 7 &a .2
Parties may substitute the above by proper notice.
K. FLORIDA LAW
Both parties shall at all times comply with the Laws of the State
of Florida and Monroe County. Further, RESIDENT agrees that the
proper jurisdiction and venue of any claims arising under this
agreement shall be in Monroe County, Florida.
OF RESIDI"4
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SIGNATURE
5
WITNESSES AS TO RESPONSIBLE PARTY
DATE : 4 t- ,3
DATE: 1 -! 3- % 3
DATE:
APPROVED:
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SIGNATURE OF RESPONSIBLE TY
SIGNATURE OF DIRECTOR, BAYSHORE MANOR
SIGNATURE OF EXECUTIVE DIRECTOR,
MONROE COUNTY SOCIAL SERVICES DEPARTMENT
SIGNATURE OF DI
DIRECTOR,
COMMUNITY SERVICES DIVISION
SIGNATURE OF MONROE COUNTY ADMINISTRATOR
This is to certify that this AGREEMENT as approved by Bayshore
Manor amd the Monroe County Administrator was ratified by the
Monroe County Board of Commissioners at it's meeting held on the
/0-*�'4 day of 19 93
(SEAL)
ATTEST:DANNY L. KOLHAGE, CLERK
OF THE CHAIRPERSON
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By MONROE COUNTY BOARD OF
Deputy C1 k
COUNTY COMMISSIONERS
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