I want to begin by thanking the Department of Medical Assistance Services (DMAS) and the Department of Behavioral Health and Developmental Services (DBHDS) for the thorough review of Vanguard Landing. I appreciate the care taken to visit the setting, interview individuals and staff, review documentation, and provide the public with an opportunity to comment. The heightened scrutiny process is important because the HCBS Settings Rule is ultimately about the everyday experiences, choices, rights, autonomy, and community integration of people with disabilities.

After reviewing the materials posted for public comment, I have significant concerns about finding Vanguard Landing compliant with the HCBS Settings Rule based on the evidence currently available.

I recognize that Vanguard Landing is a relatively new setting and that some of the issues identified through the review may be addressed as the organization develops. However, compliance with the HCBS Settings Rule should be demonstrated through the actual experiences of individuals receiving services, not simply through policies stating that individuals have certain rights or opportunities.

Several findings in the review concern me. In particular, the descriptions of scheduled and group activities, provider transportation associated with planned activities, communal meal practices, and limited documentation demonstrating individualized community participation raise questions about whether the service model is sufficiently driven by each individual's choices, preferences, and person-centered plan.

I am also concerned about whether the record sufficiently demonstrates meaningful interaction with people who are not receiving disability services and opportunities for competitive integrated employment. As Vanguard Landing grows, these issues become even more important. The availability of housing, activities, meals, transportation, and other services within a setting should not diminish meaningful opportunities for individuals to participate in the broader community.

I also have concerns about the reported immediate discharge of an individual that resulted in the person leaving their residence. I appreciate the need for providers to respond quickly when there is an immediate health or safety concern. However, emergency safety intervention, termination of services, and termination of someone's tenancy are different actions and should be addressed consistent with the rights and protections afforded to individuals receiving HCBS.

I carefully considered Vanguard Landing's responses to the findings. Some of the explanations and corrective actions are encouraging. However, policies and assurances that individuals can make choices are not the same as evidence that individuals are routinely making those choices and receiving the individualized supports necessary to carry them out.

Consistent with the principles and requirements of the HCBS Settings Rule, I believe the record should demonstrate through actual practice that individuals have meaningful opportunities to choose their own community activities; have schedules based on their individual preferences and needs; have access to transportation and staffing necessary to pursue those choices; interact meaningfully with people who do not receive disability services; pursue competitive integrated employment when desired; and exercise genuine control over their meals, visitors, schedules, and daily lives.

I was also struck by the fact that, after reviewing Vanguard Landing's extensive response, DMAS stated that it continued to stand by the accuracy of its original site review. I believe those findings deserve significant consideration in determining whether the setting has demonstrated compliance.

I appreciate Vanguard Landing's willingness to respond to the concerns identified through the review and to make changes. However, corrective policies and changes in documentation should be followed by sufficient evidence demonstrating that those changes are reflected in the day-to-day experiences of individuals receiving services.

I encourage DMAS and CMS to require sustained evidence of actual practice and individual outcomes before determining the setting compliant for purposes of Medicaid HCBS funding.

Strong oversight of HCBS settings is essential to protecting the rights, independence, choices, autonomy, and opportunities for full community participation of Virginians with developmental disabilities.