Thank you for the opportunity to provide public comment through the heightened scrutiny process. HCBS Settings Rule has been, since it's inception in 2014, the natural progression of assuring all people have the opportunity to live in an inclusive setting that meets each person's individual right's, choice and dignity.  As an advocate for person-centered services and someone who has participated in the development, implementation, oversight, and review of HCBS Final Rule compliance in multiple states, I have significant concerns regarding Vanguard Residential's compliance with the intent and requirements of the HCBS Settings Rule (42 CFR §441.530).

The HCBS Final Rule is centered on individual choice, autonomy, dignity, community integration, and the same rights afforded to individuals not receiving Medicaid-funded services. Several reported practices appear inconsistent with these principles, including:

1. Visitor restrictions requiring clearance or approval.
2. Limitations related to transportation and access to community activities.
3. Lack of documented evidence of informed choice and person-centered planning.
4. Use of language and practices that do not consistently support dignity, respect, and individual autonomy.
5. Reports of failure to follow established service or discharge plans.
6. Practices that may contribute to social isolation from the broader community.
7. Restrictions on individuals' access to personal belongings, including food and other personal items.

These concerns would warrant significant scrutiny for any Medicaid-funded residential provider seeking HCBS compliance. The presence of these issues, combined with a lack of documented remediation efforts, raises serious questions regarding whether the setting meets the requirements of the HCBS Final Rule.

Additionally, if this setting has been determined compliant, there appear to be broader concerns regarding documentation practices and whether service records adequately demonstrate the delivery of person-centered, billable HCBS services consistent with CMS expectations. Given the agency's stated plans for growth, these concerns may indicate systemic issues that could be amplified as capacity expands. Not to mention the concerns on the assurances that true choice and options counseling will be afforded to people who chose to live here and then decide to pursue services from another provider as will be their right even if they live at Vanguard. Who will assure people will have their choice of provider?  Will they be displaced from the property because they want a new residential provider because that is another significant concern?

Based on the information presented, the setting appears to exhibit characteristics associated with a congregate model of care rather than a truly integrated community-based setting. At a time when provider capacity/oversight and qualified direct support professionals remain in short supply, it is critical that expansion occur only when providers can demonstrate the infrastructure, staffing, and organizational commitment necessary to support individualized, person-centered services in full alignment with HCBS Final Rule requirements.

Thank you.

Mandy Flower MPA, M. Ed.