Response to Questions Raised at DDA Listening Sessions In Fall 2017
(DDA Representatives distributed these questions at several of their Listening sessions.)
Network Advocacy representatives answer as follows:
When the initial self-directed waiver, New Directions, became effective in FY2005, a detailed manual was also developed that laid out each team members’ role in the self-direction process and for ongoing supports. DDA has failed to keep this manual updated as their policies and procedures changed. When the two waivers were merged in FY2014, many of the specific procedural details included in the New Directions Waiver (NDW) were not transferred into the combined waiver. This has led to confusion of roles and created the potential for a duplication of some services. It has also allowed DDA to make arbitrary, unilateral changes to policies and procedures, which, in many cases, has created chaos and more confusion. For these reasons, we advocate for returning to two separate waivers: one that deals with traditional supports and one that addresses the unique needs of self-direction; or at a minimum, making SDS a separate service under the Community Pathways Waiver. We use the already-existing roles definitions from the NDW and Self-Directed/Support Broker Manual for much of our suggestions related to these roles.
Please list specific recommendations below:
Role Recommendations for the Person in Self-Directed Services
SDAN response: This role has been well-defined since the inception of self-direction. See the Community Pathways Waiver page 174 quoted below. However, additional clarifications about the self-directed service model were provided in the original self-directed-specific waiver, New Directions (ND): “New Directions is a consumer-directed service delivery system rather than a traditional provider managed system.” It also stated, “Per COMAR 10.22.05.01, “(t) through an individual directed approach, each individual, with assistance from the individual’s team, is the designer of the services and supports reflected in the Individual Plan (IP).”
From pages 174 of Community Pathways Waiver:
The merged CP waiver builds on the principles of self-determination: freedom to make choices; authority over services and supports; responsibility for organizing resources; and provision of supports necessary to live in the community. A self-directed service delivery system is not designed to increase services but rather to provide an opportunity for waiver participants to explore new ways of receiving support services. Through this mechanism, participants and their families have increased power and control over planning, budgeting, expending and managing service dollars.
Through the waiver:
- Participants plan their lives by identifying needed supports and services for inclusion in their IP;
- Participants control a fixed dollar amount for the purchase of services and supports as specified in their IP and budget;
- Participants select and arrange for services and supports to implement their IP;
- Participants are accountable for the use of public dollars in their individual budget;
- Participants are encouraged to be creative in the development and implementation of their IPs and budgets to more effectively meet their needs and more efficiently use public dollars; [SDAN comment: yet truly creative ideas are not approved by DDA and programs are basically limited to the same services available through traditional providers]
- Participants are the employer of record; and
- Participants serve as leaders and self-advocates for their self-directed services.
The merged waiver will allow participants to direct a number of their own services; utilizing a Resource Coordinator, Fiscal Management Service, and a Support Broker. Services available through the waiver are services participants may need to live successfully in their own home or their family home. Self-directed services include Respite, Supported Employment, Employment Discovery and Customization Services, Community Learning Services, Community Supported Living Arrangements, Transportation, Environmental Accessibility Adaptations, Family and Individual Support Services, Transition Services, Support Brokerage, and Assistive Technology and Adaptive Equipment.
Role Recommendations for the Family
SDAN answer: To facilitate and support the participant in self-directing services.
In all CMS documents and the original New Directions Waiver, participants and family are mentioned in tandem. Some individuals can articulate their needs, desires and goals and do not require family to assist them with SDS. But for many individuals family involvement is almost a prerequisite for self-direction. In these cases family members who have an intimate knowledge of an individual’s needs, desires and goals are often essential team members, by assisting the participant with facilitated self-advocacy. As team members, family members must remember that they are advocating for their loved one and not for themselves.
When Family Members work as staff for a Participant they must abide by the same guidelines that apply to any other staff member. The role of a staff member has been well-defined since the inception of self-direction:
- Carry out work assignments as specified by the participant/employer
- Acquire training and maintain all necessary training certifications as directed by participant and required by State law.
- Accurately record time on timesheets and complete all other required paperwork in a timely manner.
Whether or not Family Members work as staff, both the Support Broker and the Coordinator of Community Services should assist the Participant and the Family by diligently working to maintain the integrity of the Participant’s Person-Centered Plan.
Self-Direction Listening Session
We want your specific recommendations
Role Recommendations for the Support Broker
SDAN Answer: The role of the Support Broker (SB), and the distinctions between their role and that of the Coordinator of Community Services (CCS – originally called Resource Coordinator and often referred to as Service Coordinator) were very clear in the New Directions (ND) Waiver. When the ND Waiver was merged with the Community Pathways Waiver (CPW), clarifying language was removed. This resulted in confusion of roles. DDA then made unilateral changes to the roles, which resulted in some duplication of services. The Support Broker role is one required by CMS regulations and is to be a significant member of the self-direction team.
The role of the SB has been well-defined since the inception of self-direction. We feel the information about these roles that appear on pages 84-85 of the CPW (see below) need to be amended and we have provided our suggestions below. Changes should include returning language from the ND Waiver, where the role of the support broker was even more extensively discussed.
Page 4 of the ND Waiver states: “The support broker assists the individual in the management of their services and assists the individual to gain skills necessary to manage their own services. Support Brokerage is complementary of Resource Coordination [now CCS] in that it performs more day-to-day program management functions compared to the overarching planning, referral, and quality assurance duties of Resource Coordination.”
Pages 62 & 63 of the ND waiver state: “Support Brokers play an important role in facilitating effective interdependence among people with developmental disabilities who depend upon the human services system, agency and individual providers of support and services, family members and guardians. Support Brokerage differs significantly from Case Management or Resource Coordination in its intensity, frequency, level of detail and personal advocacy involved in the service. Support Brokerage is a service that assists participating individuals and families to make informed decisions about what service design and delivery will work best for them, is consistent with their needs, and reflects their individual circumstances. Support Brokerage offers practical skills in planning, service start-up, and training and assistance to enable families and individuals to remain independent.”
Pages 95 & 96 of the ND waiver state: “The Support Broker provides more intensive day-to-day program development and management support, including . . . . The information and experience gleaned from these Support Broker activities relate directly to plan monitoring and updates.”
The current waiver document actually creates confusion in the roles between SBs and CCSes. See our comments embedded in the definitions below.
Pages 84 & 85 of Community Pathways Waiver:
Service Definition (Scope):
- Support Brokerage is information and assistance in support of self-direction.
It is a service that assists participants and families to make informed decisions
about what service design and delivery (self-direction versus traditional
provider management) will:
(1) work best for the individual;
(2) be consistent with the individual’s needs;
(3) reflect their unique circumstances and provide a framework for the
participant delivery system and
(4) services shall increase individual independence and reduce level of
- Support Brokers act as human resource supports (agent of the person) to assist a participant and the
participant’s family to make informed decisions, as the employer, about what will work best for the participant and about what staff, services, and supports are consistent with the participant’s needs and reflects the participant’s unique circumstances.
- The support broker may [emphasis added] assist with day-to-day management of employees for a participant, and assist a participant and the participant’s family in the necessary and ongoing employer decisions associated with self direction. SDAN Comment: The ND Waiver states SBs “will be involved in the day-to-day management of services for an individual, and will assist individuals and families in the necessary and ongoing decisions associated with consumer direction.”
- Support broker services, if chosen by the participant, may include: SDAN comment: We are confused by this wording; having a support broker is not a choice; it is required by the waiver.
- Skills training and assistance related to employer functions, including:
- Information may be provided to participant about:
1) self-direction including roles and responsibilities and functioning as the common law employer;
2) person-centered planning and how this can be utilized to support the participant;
3) the range and scope of individual choices and options;
4) other subjects pertinent to the participant and/or family in managing and directing services;
5) the process for changing the Individual Plan (plan of care) and individual budget;
6) the grievance/complaint process;
7) risks and responsibilities of self-direction;
8) Policy on Reportable Incidents and Investigations (PORII);
9) free choice of staff/employees;
10)individual rights; and
11)the reassessment and review schedules;
- Assistance, if chosen by the participant, may be provided with:
1) initial planning and start-up activities;
2) practical skills training (e.g., hiring, managing and terminating workers, problem solving, conflict resolution);
3) development of risk management agreements;
4) development of an emergency back-up plan;
5) recognizing and reporting critical events;
6) independent advocacy, to assist in filing grievances and complaints when necessary;
7) recruiting, interviewing, and hiring staff;
8) staff supervision and evaluation;
9) firing staff;
10)participant direction including risk assessment, planning, and remediation activities;
11)managing the budget and budget modifications including reviewing employee timesheets and monthly Fiscal Management Services reports to ensure that the individualized budget is being spent in accordance with the approved IP and Budget and conducting audits;
12) managing employees, supports and services;
13) facilitating meetings and trainings with employees;
14) employer development activities;
15) employment quality assurance activities;
16) developing and reviewing data, employee timesheets, and communication logs;
17) development and maintenance of effective back-up and emergency plans;
18) training all of the participant’s employees on the Policy on Reportable Incidents and ensuring that all critical incidents are reported to the Office of Health Care Quality and DDA;
19) complying with all applicable regulations and policies, as well as standards for self-direction including
staffing requirements and limitations as required by the DDA;
20) other areas related to managing services, and supports; and
21) assisting with developing relationships between the employer, participant and family
Specify applicable (if any) limits on the amount, frequency, or duration of this service:
- Participants may utilize a family member with the exception of spouses, legally responsible adults (i.e. parents of children), and legal representative payee.
- Spouses and legally responsible adults (i.e. parents of children) may act only as unpaid support brokers.
- An individual may be the support broker of an participant, if the IP establishes that:
1) choice of provider truly reflects the individual’s preferences, wishes and desires;
2) the provision of services by the family member are in the best interests of the participant;
3) the provision of services are appropriate and based on the participant’s individual support needs;
4) the services will increase the participant’s independence and community integration;
5) if staff is a family member then no other family member is a provider of direct services;
6) there are documented steps in the IP that will be taken to expand the participant’s circle of support so that they
are able to maintain and improve their health, safety, independence, and level of community integration on an
ongoing basis should the support broker acting in the capacity of employee be no longer available.
- Support Brokers, including family members, must provide assurances that they will implement the IP as approved by DDA or their designee in accordance with all federal and state laws and regulations governing Medicaid, including the maintenance of all employment and financial records including timesheets and service delivery documentation.
- Individuals and organizations providing Support Brokerage services may provide no other service to that individual.
- Individuals and organizations providing Support Brokerage services may not provide other service to
participants which would be viewed by the Department as a conflict of interest.
- Support Brokerage services may not duplicate, replace, or supplant Resource Coordination services.
- Scope and duration of support brokerage services may vary depending on the participant’s choice and need for support, assistance, or existing natural supports.
- Start of service is limited to 10 hours per month unless pre-authorized by DDA as needed because of scope and complexity of service, dynamics, transition needs, etc.
- Service hours must be necessary, documented, and evaluated by the team.
Role Recommendations for the CCS (Coordinator of Community Services)
SDAN answer: This role has been well-defined since the inception of self-direction and is included on various pages in the Community Pathways waiver and is summarized on Page 175 (copied below). The CCS role is to oversee/support services in all areas of the individuals’ lives, not just self-direction. Original ND Waiver documents stressed that it is the “intensity” of the support that distinguishes support from CCSes versus support from SBs. CCSes are not to be involved in the day-to-day management of the program and are not expected to know the budget and staffing duty specifics. They are the “big picture” and “quality/safety assurance” team member.
Although DDA administrators have expressed concern about the possible duplication of services between the SB and the CCS, targeted case management should prevent that from happening. The CCS and the SB must work as a team for the benefit of the individual and will necessarily be involved in many of the same issues regarding the individuals they support. However, they will divide responsibilities between themselves in each situation. Since the SB and the CCS can only bill for hours they actually work, and documents are reviewed and finalized by the entire team in all cases, there should be no duplication. All team members should be involved equally in each decision/action.
From Page 175 of Community Pathways Waiver:
In general terms, the Resource Coordinator:
- Assesses the individual’s needs, facilitates person-centered planning
and assists the participant with the development of the initial and annual plan and budget; SDAN Comment: This should be the responsibility of the SB and that CCSes should just review the plan much like they would the Service Funding Plan created by traditional agencies. However, since this is a team approach to creating and implementing all parts of the plan, the CCS will still be assisting with the development of the initial plan and annual plan updates. They are team-developed documents.
- Identifies community resources;
- Monitors that health and safety needs are met by the individual’s services;
- Monitors that services are being delivered;
- Works with participants as issues arise;
- Is key to quality assurance efforts, including the assurances regarding participant health and welfare, monitoring service delivery, and fiscal accountability systems; and
- Provides checks and balances necessary for participant health and welfare and overall program integrity.
Role Recommendations for the FMS (Fiscal Management Services)
SDAN Answer: This role has been well-defined since the inception of self-direction. See the Community Pathways Waiver document pages 176-181 below. At this point in time, we do not see any reason for changes, but strongly suggest that DDA seek specific input about this from both Fiscal Management Services. We feel that relations with participants and the FMS agencies are one of the few things in the process that work quite well. There is rarely any problem dealing with them, unless DDA changes the rules without notification or consultation with the people affected by those changes.
The original ND Waiver did call for a deadline of March 31 for participants to move funds between categories in their budgets. That deadline was NOT included in the merged CPW document, yet DDA still implements that policy. We feel this arbitrary deadline should be eliminated as it creates more problems than it solves. It is virtually impossible to predict needs/changes to a plan three months before the end of the fiscal year. This is not a deadline imposed in any way on traditional agencies. The deadline rule states that after March 31, SDS participants cannot move funds between existing categories in their budgets without DDA approval and that said changes need to be made ONLY for health and safety reasons. That means that if a participant had staff take an unexpected vacation and the participant had a need for more funds in mileage, those extra funds in wages could NOT be moved into mileage unless connected to a health/safety need AND DDA agreed to let the funds be moved. This takes away the autonomy over the budget that SDS is supposed to allow its participants and this rule is NOT required by the waiver, but rather another example of an arbitrary and unilateral decision made by DDA without stakeholder input.
In this same vein, DDA directed that the FY2017 COLA only be used for staff wage increases, bonuses or benefits. This is not required by the funding legislation or the waiver documents or covered by COMAR regulations, which only addresses traditional providers. DDA relented and now allow the funds to be used for a “dire” need. Yet none of these changes have been put in writing. The initial COLA letter stated that the funds could be used for any services or supports allowed under “the Medicaid Home and Community Based Waiver,” as has been the case in the past and delineated in the ND Waiver. All subsequent “changes” to this policy has been communicated verbally and in “informal” emails with participants and their supports. The FMS is now working without clear instructions on what they can and cannot approve and participants are not able to move funds as needed.
CPW Page 176 to 181:
Fiscal Management Service (FMS)
In general terms, FMS:
- Assist the participant or legally authorized representative to:
- Manage and direct the disbursement of funds contained in the participant-directed budget;
- Facilitate the employment of staff by the participant or legally authorized representative, by performing as the participant’s agent such employer responsibilities as verifying provider qualifications, processing payroll, withholding Federal, state, and local tax and making tax payments to appropriate tax authorities; and,
- Perform fiscal accounting and make expenditure reports to the participant or family and State authorities.
- FMS includes conducting the following:
- Employer Authority tasks such as:
- assist the participant in verifying workers’ citizenship or legal alien status (e.g., completing and maintaining a copy of the BCIS Form I-9 for each support service worker the participant employs);
- assist the participant to verify provider certifications, trainings and licensing requirements;
- conduct criminal background checks;
- collect and process timesheets of support workers;
- collect and processes support worker’s timesheets; and
- operate a payroll service, (including Process payroll, withholding taxes from workers’ pay, filing and paying Federal (e.g., income tax withholding, FICA and FUTA), state (e.g., income tax withholding and SUTA), and, when applicable, local employment taxes and insurance premiums); and, distribute payroll checks.
- Budget Authority tasks such as:
- act as a neutral bank, receiving and disbursing public funds, tracking and reporting on the participant’s budget funds (received, disbursed and any balances;
- maintain a separate account for each participant’s participant-directed budget;
- track and report participant funds, disbursements and the balance of participant funds;
- process and pay invoices for goods and services approved in the service plan; and
- prepare and distribute reports (e.g., budget status and expenditure reports) to participants, DDA, and other entities as request.
- Additional functions/activities such as:
- receive and disburse funds for the payment of participant-directed services under an agreement with the Medicaid agency or operating agency as specified in authorized plan;
- provide periodic reports of expenditures and the status of the participant-directed budget as requested;
- ensure compliance with federal and State tax laws and employee wage and hour laws by appropriately managing withholdings, tax payments, and payment for workers’ compensation; and
- filing annual federal and State reports.
How can we implement a robust self-direction service option that reduces the risk of abuse, exploitation and nepotism?
SDAN Answer: One only needs to compare the outcomes for self-directing participants with the outcomes of those in traditional services to know that Maryland already has a robust SDS option. The SDS program –or New Directions–anticipated the CMS Final Rule requirements for person-centeredness and community integration by many years. SDS participants pursue their personal goals each day. People with significant or severe disabilities work, volunteer, exercise, shop and socialize in community settings on a daily basis. We encourage DDA administrators to visit SDS participants in their homes and during their community activities so they can see their remarkable achievements for themselves. We also encourage administrators to contact Support Brokers and experienced Coordinators of Community Services to learn more. Finally, DDA administrators should contact the DDA trained Delegating Nurses who visit so many SDS participants every 45 days to check on their health and welfare. Reports from those nurses regarding the well-being of SDS Participants are almost universally positive.
The best way to continue to safeguard the rights and well-being of SDS participants as well as the integrity of SDS and the public funds it uses is through the consistent involvement of a team of responsible individuals. Team members must work together to develop a personal-centered plan that truly reflects the needs, desires and goals of the participant and then provide the ongoing supports that ensure the plan is faithfully implemented. The team should include the participant, the support broker, the CCS, and usually family members. If the participant has significant medical needs, the team may also include a delegating nurse who can provide objective input regarding participant needs and well-being. As the primary advocate for the participant, the support broker should lead the way here. Frequent contact with the participant is the team’s most important contribution and safeguard—and is a particular responsibility of the Support Broker.
If the Participant is able to articulate his/her needs, goals and desires directly to the Support Broker and the CCS, there is no requirement for family involvement in self-direction unless specifically requested by the participant. However most Participants do require facilitated self-advocacy from family members who know them well. For a vulnerable individual, there is no substitute for loving advocates. In fact, family involvement is usually the best way to ensure quality services for Participants—which is why the outcomes for most people in SDS are superior to those in traditional services who rely on nonfamily members for program development and personal care. The importance of family involvement through facilitated self-advocacy is also consistent with the policies expressed by CMS recommending it.
If, through regular contacts with the Participant and Family Members, the Support Broker or the CCS or the delegating nurse concludes that any employee, including a Family Member, is not addressing the needs, desires and goals of the Participant as expressed in the person-centered plan, that person should call for a team meeting to address those concerns. If after implementing corrective actions, there are still concerns regarding the integrity of the participant’s person centered plan, the team should contact the DDA Regional Office to request another team meeting which would include DDA administrators.
DDA officials have strongly implied that there is widespread “risk of abuse, exploitation and nepotism” in SDS but have supplied no concrete evidence to support this claim– which is aimed at Family Members who work as staff for Participants. We counter that charge by noting the extraordinary sacrifices that our Family Members have been making day-in, day-out, year after year so that their SDS participants can live with purpose and dignity.
According to DDA up to 80% of SDS participants employ family members. However this figure also includes family members who work just a few hours a week and others who work only when regular employees are unavailable. For most participants family members are the only practical substitutes when regular employees are unavailable. And while some family members do work as paid employees for up to 40 hours per week, research shows that many of those same people also provide another 40 hours of unpaid supports (many families are providing supports and/or supervision 168 hours per week) —providing excellent care while saving resources for the state. (See the Wingspread Conference on Supporting Families with a Member with Intellectual and Developmental Disabilities, March 6, 2011 at https://www.waisman.wisc.edu/cedd/pdfs/products/family/Wingspread.pdf)
DDA officials have often cited an anonymous case involving multiple family members employed by the same individual who collectively earned over $90,000 annually. At face value that anecdote is alarming—and it certainly demands scrutiny. However, it is impossible to verify if it actually represents an abuse of public funding without more detail about the participant’s desires and intensity of need. If, in fact, the family employees are adhering to a properly written Person-Centered Plan, their employment may be entirely appropriate and may also represent a great cost savings for the state. As most of us are aware, DDA routinely pays providers well over $150,000 for many individuals receiving residential services. Instead of asking how many family members work for a participant and how much they are being paid, DDA should actually be asking the following essential question: Does the PCP accurately reflect the needs, desires and goals of the participant, and is that PCP being faithfully implemented?
No publicly funded program is exempt from problems, and all interested parties should work together to safeguard the rights of vulnerable individuals. Experienced support brokers, CCSes, family members, and other advocates would gladly work with DDA to develop strategies for strengthening the existing team approach in order to protect the rights and well-being of all SDS participants. However, we also affirm the remarkable success of the SDS program. And furthermore, we remind DDA that family staff members are no more likely to defraud the state than providers and non-family employees—as documented financial improprieties in traditional programs have clearly demonstrated (see separate attachment of 2009 and 2013 Audits of DDA funding issues).
SDAN ADDITION TO FORM:
Role Recommendations for DDA
Although DDA did not include this Role in this Questionnaire, we feel it is appropriate to do so.
DDA’s role has been relatively well defined since the inception of self-direction. See the excerpt below from the DDA document: Roles and Responsibilities under the New Directions Waiver.
- Assure that clear policies on self-direction are in place, and that they are communicated to participants, etc. SDAN COMMENT: DDA has failed to update the Support Brokers’ Manual for SDS policies and procedures. DDA has made arbitrary and unilateral changes without adequately communicating them with the individuals in the program or their support team, including CCSes and SBs. FY2017 COLA issues is a case in point as well as making unilateral changes in the procedures to modify budgets.
- Assure adequate training and support on self-direction and its components are available to participants, resource coordinators, support brokers, and DDA program staff. SDAN COMMENT: CCSes have never, as a whole group, received adequate training on the SDS program, but DDA required that they “write” the individual plan and budget updates for FY2017 and told SBs they would not be paid if they billed for this services. DDA has also insisted that CCSes prepare budget and plan mods, but they do not work on a day-to-day basis with the plan or individuals’ budgets, so they are unable to create these documents without SB input. Often documents that would take the SB about 10 minutes to prepare take CCSes much longer and then need to be modified by the SB to fit the DDA requirements for such documents. In some regions, DDA program staff do not seem to understand the documents they are reviewing or even the waiver itself.
- Allocate funds for participants who are self-directing. SDAN COMMENT: In FY2017, for the first time ever, DDA placed restrictions on how SDS participants could use the COLA provided by the legislature. No such restrictions were placed on the use of the funds by the legislature. It was an example of DDA changing the rules AFTER all FY2017 plans had been written without knowledge of the impending change. Many FY2017 plans had been written giving staff raises and/or bonuses with the expectation that the COLA would be used to increase mileage or service hours. These options were not available with the restrictions DDA imposed: COLA only to be used for raises, bonuses or benefits, and individuals were put in the situation to raise salaries or give unneeded bonuses while other sections of their plans were underfunded.
- Approve participants’ IP&Bs. SDAN COMMENT: DDA staff impose restrictions not called for in waiver documents based on their personal interpretation of waiver terms; such as “community” only refers to being out at a public location when CMS considers individuals’ homes in the community. DDA employees undo parts of plans that the SDS team has determined is in the participants’ best interests and reflects their needs – forcing participants to settle for an inadequate plan or to go through lengthy appeals processes.
- Approve changes to IP&B’s if new services or non-waiverable services are being added. SDAN COMMENT: Non-waiverable services can no longer be added and it is nearly impossible to get needed services added by DDA without first going through an appeal of a denial.
- Take appropriate steps to minimize liability associated with self-direction services. SDAN COMMENT: Never heard this issue discussed nor have any idea what it would entail.
- Establish and maintain guidelines and procedures for restricting self-directed services for participants who violate policies or who are otherwise unable to self-direct. Assure appropriate procedures for appeals and reinstatement of self-directed services authority. SDAN COMMENT: Not sure what this means or why any individual would NOT be able to self-direct. Individuals are always able to communicate their needs and preferences to people who know how to listen.
- Contract with Fiscal Management Services to provide fiscal services to self-directing participants. SDAN COMMENT: There are two agencies in Maryland who currently provide these services in a competent and efficient manner. Some people would like to see more choices. Whether two or more agencies are able to provide this service, we feel that these agencies need to be connected to the individuals in Maryland and be provided by companies from Maryland rather than out-of-state providers. Fiscal management services in other programs that come from out-of-state agencies are not as efficiently and responsively managed as those provided under SDS.
However we add that DDA’s primary role is to work in partnership with Participants and their advocates in order to provide flexible, person-centered, family-oriented services in the Particpant’s authentic community.
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