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Investigation of Payments Made To Professional Guardian-Rebecca Fierle by AdventHealth
Investigation of Payments Made To Professional Guardian-Rebecca Fierle by AdventHealth
Made to Professional
Guardian—Rebecca Fierle
by AdventHealth
Report 479
September 2019
County Audit Division
Audit Team
Vision
The vision of the Orange County Comptroller’s Office is to be
recognized as a highly competent, cohesive team leading the
quest for continuing excellence in the effective safeguarding and
ethical management of public funds, assets, and documents.
Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
services, case management services, permanent patient services and all other services
rendered, the names of individuals to whom services were provided and payments
(types of payment) made to Rebecca Fierle” and a number of other companies affiliated
with Ms. Fierle, including Geriatric Management, Inc. and Geriatric Management, LLC2.
In response to the Order, AdventHealth provided 6,936 3 invoices. Based on the number
of documents provided and the issues we previously reported, the Court Monitor
requested our assistance reviewing the invoices to determine the amounts received by
Ms. Fierle from AdventHealth for guardianship cases that she failed to report to the
Court.
Analysis of Invoices
The total amount of payments reported by AdventHealth since 2014 4 was $3,706,609.
The chart on the following page shows the total amount of billings by year:
2Florida Department of State records list Rebecca Fierle as the registered agent and manager of
Geriatric Management, LLC. Geriatric Management, Inc. was administratively dissolved on September
26, 2014.
3 Although 7,163 physical invoices were provided, 227 appeared to be duplicates and were only listed on
the payment file once. Twenty of the duplicate invoices were paid twice as noted in Section 4, Duplicate
Payments by AdventHealth for Identical Services.
4The number of pre-January 2014 invoices was significantly lower and payment data was not provided to
confirm these amounts.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
After analyzing the invoices, we determined payments were made on behalf of 682
patients. Patient names and case numbers, included on the invoices, were compared
to Court records to determine whether the corresponding payments were related to an
Orange County guardianship case, a guardianship case in another Florida county, or
involved a patient who was never the subject of a guardianship case. We also identified
some Orange County guardianship cases that were assigned to another guardian but
AdventHealth was making payments to Ms. Fierle.
$2,000,000
$1,500,000
$1,100,037
$1,000,000
$500,000 $341,573
$0
Orange County Other County Guardianships Non-Guardianships
Guardianships
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
As the chart shows, only 210 of the 682 patients were ever under the protection of a
Court supervised guardianship case.
Number of Patients
Orange
County
Guardianships
177
Non-
Guardianships
472
Other County
Guardianships
33
After the Court issued a second Order to Produce for the documents that were not
originally provided, AdventHealth provided a payment file to the Court on August 30,
2019. We compared the payment file with the invoices previously provided and
identified the following potential issues:
• We identified 539 physical invoices totaling $307,382 that appeared to have been
paid. However, they were not included on the payment file.
• The payment file listed 900 invoices totaling $502,112 that were not provided to
the Court.
• The amount on the physical invoice did not always match the payment file
amount.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
The payments related to the 177 Orange County cases totaled $2,514,716 6. None of
these amounts were reported to the Court as required by Florida law.
An additional $341,573 was paid to Ms. Fierle related to other Florida guardianship
cases. In summary, the total amount paid to Ms. Fierle from AdventHealth related to
Florida guardianship cases was slightly less than $3 million dollars.
When guardian fees are submitted to the Court for approval, the Court should consider
the nine criteria of F.S. 744.108, including, but not limited to, the fee customarily
charged in the locality for similar services. The Court has determined that the maximum
amount that will be paid for Orange County guardian fees is currently $65/hour. The
invoices indicated that AdventHealth is currently paying $130/hour. Therefore, in
bypassing the court approval process, Ms. Fierle’s fees were not consistent with the
fees determined to be reasonable by the Court.
5We did not have access to Court records in the other Florida counties and were unable to determine
whether these amounts were reported to the applicable Courts.
6 Submitted on 4,040 separate invoices.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
Any violation of F.S. 744.446 could subject the guardian to removal and imposition of
personal liability. As noted previously, Ms. Fierle’s authority as a guardian in Orange
County ended on July 11, 2019.
For example, Ms. Fierle submitted an invoice to AdventHealth for guardian fees for May
2016 services totaling $2,222.64. The description and charge for each item on the
AdventHealth invoice were identical to those items on an invoice later submitted to the
Court—except for the hourly rate. AdventHealth was billed $120/hour and the same
services were also approved for payment by the Court from the ward’s assets at
$64/hour7 for a total of $1,192.24.
7
$64/hour was the rate approved by the Court at the time
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
Ms. Fierle submitted an invoice to AdventHealth for another ward on 11/01/16 for
October 2016 guardian fees totaling $2,282.32. The same fees for October 2016 were
submitted to the Court in July 2017 for a total of $1,223.92 and paid from the ward’s
funds.
In addition to guardian fees, other expenses for the benefit of Ms. Fierle’s wards were
also approved for payment multiple times—once by AdventHealth and again from the
ward’s assets. These payments included attorney fees, home care services, and rent
payments.
Trusts Many of the guardianship cases involved wards who had established trust
accounts. Detailed trust account information is typically not submitted to the Court in
the guardianship process. However, trust funds might be used for guardian fees,
attorney fees, and expenses of the ward. Therefore, there is a risk that fees could also
be reimbursed multiple times (from trust assets, the wards’ assets, and other sources)
without detection. We did not have access to any trust account statements to verify
whether any of the AdventHealth expenses were also reimbursed from trust accounts.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
We compared invoice dates with case initiation dates for each Orange County
guardianship case where Ms. Fierle submitted invoices to AdventHealth. In 53% (92 of
173) of the cases, invoices were submitted to AdventHealth at least one month before
the guardianship case was initiated.
One case included 28 invoices totaling $7,640 over the three-year period prior to
the guardianship case. In this case, the first invoice was submitted to
AdventHealth in December 2011. However, the guardianship case was not
initiated until October 27, 2014. The petition submitted by Ms. Fierle stated, “The
relationship and previous association of the proposed guardian to the ward is
none.” However, Ms. Fierle had a continuing relationship with the ward for three
years prior to the guardianship.
Ms. Fierle submitted 8 of the 10 petitions, and AdventHealth submitted the other two
petitions reviewed. Both parties should have been aware of the previous relationship
based on the prior invoices submitted by Ms. Fierle.
The invoices also show numerous instances where Ms. Fierle accessed bank
information and accounts prior to becoming a guardian. Clerk of Courts staff review the
initial inventory filed with the Court. However, the staff’s analysis typically begins on the
date the guardianship begins—which is the date the Letters of Guardianship are issued.
If the guardian is accessing and managing the ward’s assets before the guardian is
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
appointed, the Clerk’s review would only include the records after the Letter of
Guardianship is issued. This increases the risk that assets may be misappropriated.
In addition to Ms. Fierle’s activities with financial assets, we identified an invoice that
showed her involvement with a ward’s personal property before she was appointed as a
guardian. The invoice noted the following entries:
• “The ward’s apartment manager was contacted and given permission to, “empty out apt, collect
personal items, docs, mail, etc for pickup/delivery to gdn”.
• “CM went to client’s apartment bldg. to meet w/admin. And pick up mail, belongings of value (very
few) and keys to car; was assisted with items as very heavy; client’s spouse’s ashes also given to
CM; delivery of all items to office for gdn”.
Further, there was no notation included on any of the invoices indicating that the ward’s
personal items, including her husband’s ashes were delivered to the ward. Here again,
details of this relationship were not disclosed to the Court on the petition for
guardianship.
The payment file listed an additional 20 invoices that were paid twice. Each of the
payments listed the check numbers associated with each payment. This clearly
indicates that Ms. Fierle was reimbursed multiple times for the same invoice. The total
amount of overpayment related to these invoices was $8,097.
All of the duplicate payments referenced in this section are related to guardian fee
payments by AdventHealth. The duplicate guardian fees were not paid from
guardianship assets. However, by submitting duplicate billings to AdventHealth, the
guardian receives private gain from her position as the guardian. F.S. 744.446 prohibits
guardians from using their positions for private gain.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
One case was assigned to Seniors First, a non-profit organization that provides services
to the community’s vulnerable elderly. However, Ms. Fierle submitted three invoices for
“Case Management Services” on this matter. The ward died three months after case
initiation. Ms. Fierle submitted invoices for the entire time period when the case was
assigned to Seniors First. Court records confirm that Seniors First was the assigned
guardian from case initiation until it was discharged after the ward’s death.
We also identified cases where a family member was assigned as the guardian.
However, Ms. Fierle received payments from AdventHealth.
Many of the invoices submitted by Ms. Fierle included generic descriptions and/or no
support for expense reimbursements or fees for services was provided by AdventHealth
with the invoices. For example, invoices were submitted with only a vague description
of “Case Management Services”. No date of service or hours worked was included on
the invoices. The only identifying information included on the invoices was the name of
the individual and total amount charged. One monthly invoice listed one entry for case
management totaling $1,485 with no detailed description.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
In the previous investigative report issued on July 8th, we identified an instance where
the professional guardian may not have acted in the ward’s best interest. The previous
report stated:
The Ward sent the Clerk of Court’s Office a hand written letter on
04/21/2017 with a copy of a lien sale notice for her personal
storage unit. She also wrote directly on the sale notice that it
needed to be paid. The storage unit bill totaled $299.28, including
rent of $86.28, insurance of $16, and nonpayment related fees of
$197. According to a public notice in the Apopka Chief, the
contents were scheduled for auction on June 20, 2017, two
months after her plea to pay the bill was recorded in the case.
There is no documentation showing the Professional Guardian
paid the storage fee. There is no evidence that the belongings
were recovered for the Ward or next of kin.
After reviewing the invoices submitted to AdventHealth by Ms. Fierle related to this
ward, we identified the following entries:
• 03/21/17 “p/c from [ward name redacted] regarding a storage unit bill, emailed RF”
• 03/28/17 “communication regarding calls regarding storage and communication regarding issue
with endo doctor”
• 03/30/17 “Visit client at Metro West SNF. Discussed pending move and storage unit.”
• 03/31/17 “bill paying, ie. Reviewing bill & writing checks”
• 04/04/17 “phone call from [ward name redacted] regarding storage, communication with
Rebecca Fierle”
• 04/06/17 “phone call from [ward name redacted] regarding storage unit, emailed Rebecca Fierle”
• 04/11/17 “Call regarding storage units, emailed to care managers”
• 04/30/17 “reviewing ward’s bills and financial status and writing checks accordingly”
• 05/30/17 “phone call form [ward name redacted] regarding belongings, emailed case manager”
The invoices listed four phone calls from the ward to the professional guardian 8
regarding the storage unit bill and her belongings. There were an additional three dates
noted where the storage unit was discussed and two entries for paying bills and writing
8
Or one of her employees
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
checks during this time. For these nine invoice items, the guardian was paid $288.75 to
discuss the storage unit and pay bills. However, the storage unit bill of $299.28 was not
paid to keep the ward’s possessions from being sold at auction. It should also be noted
that the total amount of all invoices paid to Ms. Fierle by AdventHealth related to this
ward was $44,376 over less than four years.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
Ms. Fierle billed $3.9 million for services she provided to 682 patients. This amount
included billings for two distinct groups of patients. The first group includes 210 patients
who were wards in the Florida guardianship system. The second group (Group 2) is the
remaining 70% of patients (472 of 682) who were never guardianship wards.
Competent individuals are permitted and encouraged to sign durable powers of attorney
or health care surrogate forms. This enables people to designate another person to
make health care decisions on their behalf if they are ever incapacitated and unable to
make those decisions for themselves. If an incapacitated person has never designated
someone to act on his or her behalf, a health care proxy can be appointed to make
decisions under certain circumstances.
The process to appoint a health care proxy is detailed in F.S. 765.401. However, the
statute limits potential health care proxies to eight classes of people—generally family
members, close friends, and clinical social workers. It also permits court appointed
guardians to serve as health care proxies.
Ms. Fierle is likely not related or a close friend of the Group 2 patients. It does not
appear that she would qualify as a proxy—especially since she was not appointed as a
guardian in any of the 472 Group 2 cases. Therefore, it is unclear how Ms. Fierle could
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
have become a health care proxy with the authority to make life and death decisions for
Group 2 patients 9.
DNRs
We identified numerous entries referencing DNRs, hospice, and other life and death
health care decisions, in the invoices that we reviewed. Therefore, we believe that it is
likely that Ms. Fierle obtained DNRs for the Group 2 patients who might still be living or
have already died based on these DNRs.
On July 15, 2019, the Court entered an order nullifying all of the DNRs that Ms. Fierle
executed on behalf of her Orange County guardianship wards. However, that order
provides no protection for the Group 2 patients because they are not under the
protection of the Florida guardianship system.
One reason the Court entered that order was evidence showing that Ms. Fierle
executed DNRs—even when one of the wards clearly expressed his objection to being
placed under a DNR. The Court, law enforcement, and patient families should be
aware that Ms. Fierle has made similar critical decisions for the Group 2 patients without
the Court’s knowledge or approval. Those decisions should be reviewed to confirm that
they are appropriate for the Group 2 patients.
9765.401(1)(a) provides that a treatment decision may be made before the guardian is appointed.
However, the statute implies, but does not state, that guardianship proceedings should follow after
emergency treatment decisions.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
• “FV to client…well dressed and groomed. Recent hair cut… swears@staff during care…DNR on
file.” The same individual was invoiced in October 2013 for "Comm re dc plan to SNF w/Hospice
etc".
• The following entries were listed on the same invoice:
o 03/05/18 — “monthly check in with ward – he is still content in his setting. Updated by
administrator, no further needs”
o 03/10/18 — “comm arnp and admin re non-compliant behaviors, DNR status.”
• Initial contact by Ms. Fierle with the patient on 08/02/10 according to the invoices. The following
entries were also included:
o 11/09/10, “Ph call with hospice re:proxy”
o 11/11/10, “Ph call with hospice re:proxy”
o 11/12/10, “P/C from hospice nurse re: fax copy of proxy”
o 11/19/10, “numerous calls with hospice”
o 11/19/10, “Fax DNR to facility”
o 01/31/11, “FV Client appeared well-dressed and clean. Nsg reports client is stable.”
• Entries related to a fourth individual:
o 10/02/14, “P/C regarding client being admitted today, his history, and needs. PC with
SNF regarding DNR status.”
o 10/21/14, “Comm with RF regarding incapacity and DNR status”
o 10/23/14, “FV to see client at SNF. Client pleasant during visit. He propels himself
throughout facility and outside to smoke. Chart reviewed. No concerns expressed by
client or staff. No behavior issues at this time. Client adjusting well to SNF.”
o 10/23/14, “evaluated by psychiatrist. No psych meds ordered. No behavior concerns.
Incap pending.”
o 12/10/14, “Scan DNR and incap and upload to server”
In addition to the health care decisions, we identified numerous instances where Ms.
Fierle exercised control over the patients’ assets without a petition for guardianship.
Ms. Fierle would not be subject to any oversight by the Court in the cases where she did
not petition for guardianship. We were unable to determine whether Ms. Fierle or her
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Phil Diamond, CPA, Orange County Comptroller
September 10, 2019
employees had the legal authority 10 to access the patients’ bank accounts or other
assets because no documents were filed with the Court.
The following are examples from the invoices indicating Ms. Fierle was accessing
patient financial assets without Court supervision:
• “Told him he has money in account if he needs snacks or anything. States he’s ok.” The same
patient had this entry as well, “Resend estate balance to daughter”
• “reviewing wards bills and financial status and writing checks accordingly”
• “He is medically stable with no needs at this time. He signed documents needed for loan
forgiveness.”
• “research for life insurance surrender amount”
• One patient had the following entries:
o “Met with client to discuss a pool trust. He also signed an HCS form naming his sister.
o “Initial set-up of bank acct in system/prepare check for deposit” Another entry on the
same day, “Go to FCB to deposit check”
o “Visited with client and he signed check for guardian pool trust.”
Designation as a health care surrogate would not provide access to financial documents
other than to apply for private, public, government, or veterans’ benefits to defray the
cost of health care. Although other legal documents may have been signed authorizing
Ms. Fierle and/or her employees to access assets and make health care decisions,
these documents appear to be used by a professional guardian outside of Court
supervision to circumvent the Court’s oversight.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Orange County Comptroller
September 10, 2019
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Orange County Comptroller
September 10, 2019
(a) Have any interest, financial or otherwise, direct or indirect, in any business
transaction or activity with the guardianship;
(3) Any activity prohibited by this section is voidable during the term of the guardianship or
by the personal representative of the ward’s estate, and the guardian is subject to removal
and to imposition of personal liability through a proceeding for surcharge, in addition to any
other remedies otherwise available.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Orange County Comptroller
September 10, 2019
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Orange County Comptroller
September 10, 2019
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Orange County Comptroller
September 10, 2019
1. Personal accounts;
2. Joint accounts created with the intent that only the elderly person or
disabled adult enjoys all rights, interests, and claims to moneys
deposited into such account; or
3. Convenience accounts created in accordance with s. 655.80; or
e. Intentionally or negligently failing to effectively use an elderly person’s
or disabled adult’s income and assets for the necessities required for that
person’s support and maintenance, by a caregiver or a person who stands
in a position of trust and confidence with the elderly person or disabled
adult.
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Investigation of Payments Made to Rebecca Fierle by AdventHealth
Orange County Comptroller
September 10, 2019
Avg. Avg.
Amount Amount
Total No. of per Total No. of per
Ward Charges Invoices Invoice Ward Charges Invoices Invoice
1 $50,871 54 $942 27 $24,449 32 $764
2 $47,381 35 $1,354 28 $24,352 43 $566
3 $44,376 45 $986 29 $24,244 45 $539
4 $41,828 85 $492 30 $24,224 45 $538
5 $38,893 59 $659 31 $24,188 28 $864
6 $38,692 53 $730 32 $24,150 31 $779
7 $36,414 20 $1,821 33 $24,097 46 $524
8 $36,275 62 $585 34 $24,022 27 $890
9 $35,185 65 $541 35 $23,498 35 $671
10 $33,263 27 $1,232 36 $23,332 55 $424
11 $32,045 52 $616 37 $22,902 53 $432
12 $31,669 47 $674 38 $22,611 45 $502
13 $30,521 86 $355 39 $22,594 47 $481
14 $29,514 49 $602 40 $22,436 45 $499
15 $28,832 43 $671 41 $22,124 26 $851
16 $28,328 51 $555 42 $22,111 32 $691
17 $27,511 40 $688 43 $22,055 38 $580
18 $27,361 30 $912 44 $21,638 50 $433
19 $27,306 54 $506 45 $21,622 57 $379
20 $26,952 42 $642 46 $21,569 27 $799
21 $26,779 31 $864 47 $21,478 33 $651
22 $26,774 41 $653 48 $21,211 34 $624
23 $26,530 75 $354 49 $21,057 27 $780
24 $26,240 36 $729 50 $20,922 26 $805
25 $25,138 28 $898 51 $20,441 37 $552
26 $25,099 58 $433
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