Unfortunately, the present guidance document fails to appreciate the complex issues surrounding court appointed legal guardians and their responsibility for ensuring the health, safety and wellbeing of individuals who have a history of dangerous behavior that has put themselves and others at risk of harm. It would be helpful if the document can provide guidance for providers on how to include legal guardians in the discussion of rights restrictions. There are no legal protections for a provider who challenges a legal guardian using HCBS rights as an argument. In other words, if an individual is harmed or injured as a result of their behavior (or injures/harms others) and the provider chose not to follow the guardian's stated recommendations, this guidance document provides no protection for the provider. The hyperbolic language of this document ("ONLY", "cannot be modified at any time") suggests that providers should challenge or test a legal guardian's decision making authority. Unfortunately, the present guidance document fails to appreciate the legal ramifications this will have on providers. Moreover, a longer-term consequence of this might be that providers may choose not to provide supports/services to individuals with a history of dangerous behaviors.

Second, the present guidance document fails to acknowledge and incorporate historical information from other professionals / providers as evidence for a necessary restriction. What if a medical doctor orders a specific restriction for health and safety reasons? Will a provider still need to document the evidence of risk in progress notes, data collection, etc. "before restricting them in any way"? What if a psychiatrist or another mental health professional recommends the removal of guns / knives from the home because of previous suicide attempts? Should a provider still collect their own evidence/data for 6-months before following the other professional's recommendations? The guidance document fails to appreciate both a multi-disciplinary approach and the use of evidence from other providers when making decisions about appropriate care. Rarely is a provider alone in making all the decisions for the individual's safety and wellbeing. What should providers do with data or evidence from previous service providers that show a history of previous attempts and/or history of failed interventions that resulted in injury to the individual/others or discharge from services. Currently, there is no guidance on how a provider can use this valuable historical information from other providers to help maintain the health and safety of the individual (e.g., to implement a life saving restriction upon admission/starting services).

Third, there are no references to empirically supported or evidence-based practices. Some of the examples given in the guidance document suggest practices that go against current empirically validated treatment recommendations for individuals diagnosed with Prader-Willi syndrome and substance use/abused disorders (e.g., Duis, J., van Wattum, P. J., Scheimann, A., Salehi, P., Brokamp, E., Fairbrother, L., Childers, A., Shelton, A. R., Bingham, N. C., Shoemaker, A. H., & Miller, J. L. (2019). A multidisciplinary approach to the clinical management of Prader-Willi syndrome. Molecular genetics & genomic medicine, 7(3), e514. https://doi.org/10.1002/mgg3.514 ; or McGovern, M. P., & Carroll, K. M. (2003). Evidence-based practices for substance use disorders. The Psychiatric clinics of North America, 26(4), 991–1010. https://doi.org/10.1016/s0193-953x(03)00073-x ). The present guidance document can be improved if it balances an individual's rights and freedoms with their right to effective, evidence-based treatment. 

I hope the above comments are helpful to the agency / author.