11/10/1993 Agreemente
� �YSHORE DIANOR
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 day of A10(),Xp4,ag L 19�,
by and between the County of Monroe, State of Florida,
hereinafter called "COUNTY" and KldF✓ayE 6-. %h-LE%
hereinafter called "RESIDENT", and GENtJy `T Va)Z
hereinafter called "RESPONSIBLE PARTY".
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'S 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
1
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. Subject to the availability of funds, 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: 0
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 COUNTY 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
2
not exceeding the maximum rate as may from time to time
be adjusted by COUNTY.
7. Shall, if funds for medication expenditures become
unavailable, make arrangements for payment of medication
expenses which Bayshore Manor cannot pay or arrange for
RESIDENT'S transfer to an alternative, appropriate
facility.
8. Shall maintain on file with Bayshore Manor an up-to-date
name, address and telephone number for RESPONSIBLE PARTY
or next of kin.
9. Other: `roAwLiiALn -ME -rx9PA n�',ruir AZh9t&r.-w D.7ribAr r A,InIA,#
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C. FINANCIAL RESPONSIBILITY
RESIDENT and/or RESPONSIBLE PARTY agree to pay COUNTY
$ Mo-op per month for use of COUNTY'S Bayshore Manor
facility.
Monthly payment shall be derived from the following sources:
1. Personal funds of RESIDENT
2.
RESPONSIBLE PARTY
will pay
$ 340- 3j
3.
Monthly income of
RESIDENT:
Social Security income $ 632.y9
Supplemental Security Income $ p--
Railroad Retirement income $ ._ p-
Civil Service income $ ..p—
V.A. Pension $ 19o.2p
Other $ ,2q. pa
$ _
D. STANDARD ADMISSION WAIVER
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
3
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.
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 shall automatically 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
4
Unless otherwise terminated, this agreement shall remain in full.
force and effect until such time as a new agreement is duly
executed.
I. 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.
J. NOTICE
Any notice required by this agreement to be made by either party
shall be made as follows:
BAYSHORE MANOR
Name: &fl Errr e. [uje�J u�. D-
RESIDENT/RESPONSIBLE PARTY
Name: 4pa-Y T. ✓ a
Address: SIOD CQLLerCi RpAV Address: 6yl? ;NV `1"Z"4CZ -4/
xiy Ir ira ri., 33Dily GIeV WMIT, FL.. 330 fa
Phone: ( a) Z 7 `f -g 96 6 Phone: (3,OV z9 6- syo.7
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.
5
WITNESSES AS TO RESIDENT
aooL ola" -
WITNESSES AS TO RESPONSIBLE PARTY
DATE: ► f1
DATE: 11'IS'f3
APPROVED:
SIGNA
SIGNATURE OF RESIDENT
SIGNATURE OF RESPONSIBLE PARTY
OF DI
, BAYSHORE MANOR
SIGNATURE OF EXECUTIVE DIRECTOR,
MONROE COUNTY SOCIAL SERVICES DEPARTMENT
SIGNATURE ONZOSROE COUNTY ADMINISTRATOR
Arvc--a U-119*-15
APPROVED AS TO F^^-.?
GAL SUF.-lCJEVCy,
Flyys O'ice
A
DURABLE POWER OF ATTORNEY
KNOW ALL MEN BY THESE PRESENTS that I, GENEVIEVE TILLER, the
undersigned, currently residing at 1300 - 15th Court #39, Key West,
Florida 33040 do hereby make, constitute and appoint my daughter,
JENNY LEE VERE, my true and lawful attorney -in -fact for me and in
my name, place and stead and on my behalf and for my use and
benefit to act either jointly or individually for the following
purposes:
1. To exercise or perform any act, power, duty, right or
obligation whatsoever that either I now have or may hereafter
acquire; the legal right, power of capacity to exercise or perform
in connection with, arising from, or relating to any person, item,
transaction, thing, business, property (real or personal, tangible
or intangible), or matter whatsoever.
2. To request, ask, demand, sue for, recover, collect,
receive, and hold and possess all such sums of money, debts, dues,
commercial paper, checks, draft accounts, deposits, legacies,
bequests, devises, notes, interests, stock certificates, bonds,
dividends, certificates of deposit, annuities, pension and
retirement benefits, insurance benefits and proceeds, any and all
documents of title, chooses in action, personal and real property,
intangible and tangible property and property rights and demands
whatsoever, liquidated or unliquidated, as now are or shall
hereafter become, owned by or due, owing, payable, or belonging to
me or in which I may or hereafter acquire interest, to have, use
and take all lawful means and equitable and legal remedies,
procedures, writs, in my name, for the collection and recovery
thereof, and to adjust, sell, compromise and agree for same, and to
make, execute, and deliver on my behalf and in my name all
endorsements, acquittances, releases, receipts or other sufficient
discharges for the same, including by way of illustration, but not
limitation, to collect, receive, hold and possess all such sums of
money in and future deposits, to and interest credited to any of my
bank accounts, certificates of deposit, savings and loan
association accounts, or credit union accounts, or any other
similar accounts.
3. To lease, purchase, exchange, and acquire and to agree,
bargain, and contract for the lease, purchase, exchange and
acquisition of, and to accept, take, receive, and possess any real
or personal property whatsoever, tangible or intangible, or
interest thereon, on such terms and conditions and under such
covenants as said attorney -in -fact shall deem proper.
4. To conduct, engage in, and transact any and all lawful
business of whatever nature or kind to me, in my behalf, and in my
name.
5. To make, receive, sign, endorse, execute, acknowledge,
deliver and possess such applications, contracts, agreements,
options, covenants, conveyances, deeds, trust deeds, security
agreements, bills of sale, leases, mortgages, assignments,
insurance policies, bills of lading, warehouse receipts, documents
of title, bonds, bills, debentures, checks, drafts, bills of
exchange, letters of credit, notes, stock certificates,
certificates of deposit, satisfaction and releases of mortgages,
liens, judgements, security agreements, and other debts and
obligations and such other instruments in writing of whatever kind
and nature as may be necessary or proper in the exercise of the
rights and powers herein granted.
6. I grant to said attorney -in -fact full power and authority
to do, take, and perform all and every act and thing whatsoever
requisite, proper, or necessary to be done in the exercise of any
of the rights and powers herein granted, as fully to all intents
and purposes as we might or could do if personally present, with
full power of substitution or revocation, hereby ratifying and
confirming all that said attorney -in -fact or her substitute or
substitutes shall lawfully do or cause to be done by virtue of this
power of attorney and the rights and powers herein granted.
7. This instrument is to be construed and interpreted as a
general power of attorney. The enumeration of specific items,
rights, acts or powers herein is not intended to limit or restrict
and is not to be construed or interpreted as limiting or
restricting the general powers herein granted to said attorney -in -
fact.
8. This Durable Power of Attorney shall not be affected by
the disability or incapcity of myself as principal, except as
provided by statute, it being my intent that this Durable Power of
Attorney be exercisable and continue in full force and effect
notwithstanding any later mental or physical disability or
incapacity of myself, and shall be valid until I die or revoke the
Power of Attorney.
9. The rights, powers and authority of said attorney - in - fact
herein granted shall commence and be in full force and effect on
the date I sign this Power of Attorney and be in effect hereafter
until revoked by me in writing.
WITN�SS HEREOF I have set my hand and Seal thisId— day
of , 1993.
GENEVIEVE TILLER
Witness 0 i
printed, name
Witness: PQ Nk)�-�
rinted name
STATE OF FLORIDA
COUNTY OF MONROE
The foregoing instrument was acknowledged before me this 2 day
of 4&L , 1993 by GENEVIEVE TILLER, who is personally
known to me, or who produced as identification,
and who did/did not take an oath.
r `
Nota;j, ublic
Typed/Printed name of Notary
NOTARY PUBLIC -STATE OF FL.
My Commission Expires:
(SEAL)
ROBERT T. FELDMAN
14- •f MY COMMISSION N CC 206641 EXPIRES
,fr07{ June 4, 1%6
?� ^ BONOFO THF�, !qnV FAIN INSURANCE, INC.