National Association to Stop Guardian Abuse: AdventHealth outlines guardianship changes after paying disgraced guardian nearly $4 million

Sunday, February 9, 2020

AdventHealth outlines guardianship changes after paying disgraced guardian nearly $4 million | Exclusive

AdventHealth Orlando CEO Daryl Tol in his office. Thursday, Nov. 21, 2019. Tol revealed changes the hospital is making to its guardianship practices in the wake of the Rebecca Fierle scandal. (Sarah Espedido / Orlando Sentinel)

AdventHealth Orlando will make sweeping changes to how it handles court-appointed guardianships for vulnerable patients after a probe found the hospital paid disgraced guardian Rebecca Fierle nearly $4 million to care for hundreds of its incapacitated patients.

The hospital will no longer pay private guardians to take on cases, will form a review panel to ensure at least two doctors determine whether patients can no longer make their own decisions before asking a judge to appoint a guardian, and will provide more training to care managers, said Daryl Tol, president and CEO for AdventHealth’s Central Florida Division, in an exclusive interview with the Orlando Sentinel.

The changes come after the hospital hired an outside law firm to conduct an audit of its campuses in Orange, Seminole and Osceola counties. Tol said the hospital will also put its political heft behind statewide reforms for the troubled guardianship program, advocating for lawmakers to increase funding, add more oversight for guardians and clarify the legal definition of incapacity.

“We have put too much trust in a flawed system,” Tol said. “And that is not something we want to continue doing or want to do again.”

Tol, who did not provide the Sentinel with a copy of the audit during an interview Thursday, said no wrongdoing was found on the part of hospital staff. He said the Sentinel’s reporting about flaws in the guardianship system served as a “positive catalyst” for some of the changes.

Fierle first came under scrutiny when one of her incapacitated clients, 75-year-old Steven Stryker, died at a Tampa hospital in May after staff were unable to perform life-saving measures because of a “do not resuscitate” order Fierle filed against his wishes and refused to remove, according to state reports. Less than a year before his death, AdventHealth Orlando had petitioned a judge to appoint Fierle as Stryker’s guardian when he was a patient there, despite him having a health-care surrogate.

The embattled guardian later admitted to routinely filing DNRs on her wards.

An audit by the office of Orange County Comptroller Phil Diamond later found Fierle improperly billed AdventHealth close to $3.96 million over a decade for services she provided to 682 of its patients, either as a court-appointed guardian, durable power of attorney, heath care surrogate or proxy. The hospital system paid at least $3.7 million, according to Diamond’s office.

Tol said the hospital spends about $30 million a year on care management for patients, which until now has included payments to guardians along with other costs, such as helping patients transition to group homes or other facilities.

As an example of the how challenging it can be to find long-term care for patients, he said employees once made more than 1,000 phone calls to find a group home for a man who was able to make his own decisions, but couldn’t live alone and didn’t have any money or family. AdventHealth Orlando is now paying for the man to live in a group home in California, he said.

About 70 patients a year are admitted to one of the hospital’s Orlando campuses who end up needing a court-appointed guardian because they can no longer make decisions and do not have family or friends who can do so for them, he said.

“If you call a smaller hospital, it could literally be years in between these situations because of the volume,” Tol said. “Because of the 140,000 admissions a year, it just so happens that a rare thing happens more frequently here.”

Typically, private and public guardians are paid through the ward’s assets or by the state to make all legal, financial and medical decisions for incapacitated people. But the multimillion-dollar arrangement, which is not allowed under Florida law without a judge’s approval, has been described by experts as virtually unheard of in the industry. It is problematic, they say, because the hospital’s wishes could conflict with the best interests of the ward.

“I would say, with regret, that it was a misunderstanding and the payments were made in good faith for the services as deemed appropriate by our care management team,” Tol said.

At times, Fierle submitted identical invoices to the hospital and the court to get paid twice for the same service and net three times the court-approved maximum fee, according to the comptroller’s probe. The probe only reviewed AdventHealth hospitals in Orange, Seminole and Osceola counties but did not look at the company’s other entities, which likely also paid Fierle.

“We were unaware that there was double billing happening, and we were an unwitting victim of that,” Tol said.

Tol said AdventHealth’s relationship with Fierle developed over 20 years. The hospital company used other guardians but primarily relied on Fierle because she was “responsive” and would take cases quickly.

“She would take on cases very easily, was easy to work with from the perspective of the team’s ability to get in touch with her,” he said. “And yet, of course, the team didn’t realize the things that have been brought to light. … Sometimes there are bad actors in the middle of a lot of good people trying to do good work.”

AdventHealth spokesman Bryan Malenius previously told the Sentinel the hospital petitions a judge to appoint a guardian as a “last resort” because it can’t discharge patients unless they have a safe place to go. AdventHealth asks the Florida Department of Children and Families to step in when those situations arise, but the state agency regularly declines, Tol said.

“We have faced over the years a very challenging dynamic in which DCF will reject the responsibility for the situation, and frankly, just leave it in our hands,” he said. “That leaves our team of advocates dealing directly with the courts and with guardians.”

DCF spokeswoman Kristi Gray has previously said guardianship is “not a DCF process.”

“When the agency identifies a need for guardianship on an open case, our attorneys navigate that judicial process,” Gray said in a statement in October.

Tol said AdventHealth has petitioned the courts for professional guardians in order to expedite safe discharges to a “better and healthier location” because the wait for a public guardian to be appointed can be lengthy.

“The hospital is not intended to be a long-term safe residential facility,” Tol said. “If the public guardian is not readily available, it is not in the interest of the individual when they’re not in an acute health care episode to remain in the hospital setting surrounded by other very sick people. They are much better off in the appropriate care setting.”

The hospital CEO and president said AdventHealth believes Florida should clarify and strengthen the responsibility of DCF to care for incapacitated people.

“We think there needs to be an intensive review of cases where DCF has refused to assist patients so that at least it’s understood why that was the case,” Tol said. “... We’re not looking to point fingers or identify bad guys, other than perhaps the guardian in question, but aside from that, we just think it’s got to be a better team effort.”

The AdventHealth Orlando CEO said the hospital is cooperating with law enforcement in criminal investigations into Fierle but the company is not pursuing independent legal action against the former guardian.

“We want to be a partner with all those trying to get to the bottom of it in this specific case,” Tol said.

Fierle, who has resigned as a guardian, is not currently facing any charges.