First-Thank you for presuming competence of each individual receiving services from HCBS providers. That is valuable and as an occupational therapist and therapeutic consultation provider who strongly believes in the right of every individual to express their voice and choice, I must acknowledge that.

However, there is so much more work needed on this document to account for individuals who come to various settings with established plans of care to address specific health and safety needs. As an occupational therapist, I examine the impact of environment and task demands on individual performance, therefore in the given example of the person with Prader-Willi Syndrome, alarms may be a good first option, but there should not be a time when alarms are not in place given that individual’s diagnosis and pre-disposition to food intake that puts them at high risk for other health complications, you must start with a safe option. For Jane the individual who tends to wander, door alarms, and some type of safety tracking device may be indicated at the time of transition based on previous strategies that were successful. Why would should a provider be put at risk for a individual to be injured unnecessarily. This “guidance” is not taking into account the situations that those of us who have worked in these settings experienced on a daily basis. As other commenters have noted some of these suggestions are not inline with best practices for the conditions you referenced & fail to insure the individual’s health & wellness at baseline.

 To provide an example from my personal life experience with a parent with a disability—Bed rails were classified as a restraint in hospitals and therefore were no longer allowed to be up on both sides due to increased fall risk and even death in patients. However, my father was a quadriplegic with no controlled motor movement below the neck and a history of spastic seizures that made him a significant fall risk in a narrow hospital bed. This was highly documented. However due to policies created that listed the above rules for hospitals and skilled nursing facilities, each time he went to one we had to worry if he would fall out of bed with a fall mat and sometimes a half railing. He was able to advocate for his needs with his family by his side, but even then there was pushback because of the policies that were in place to prevent restraint that actually caused him physical harm. 

Furthermore, as currently presented this guidance is failing provide safe solutions at baseline and allow for supported decision making and the role of the legal guardian in the decision making process. How do those conflicts get resolved when the legal guardian disagrees with the individual? What is the role of the provider in those circumstances?

The goal of providing supports to individual’s with disabilities is to provide the right level of support at the right time. I recognize the need to be as least restrictive as possible, but give the unique set of circumstances of each individual, you must account for past experiences yo be taken into consideration for modifications  from the beginning rather than allowing an individual to be put in harm’s way before taking action. Any guidance from an agency should account for complex situations and support provider decision making rather than making it more burdensome and confusing.