HCBS Settings Rule and Stakeholder Partnerships

SCARY OR NOT SCARY: UNDERSTANDING HCBS
SETTINGS RULE
Sierra Royster, Director of Innovation
Association of Programs for Rural Independent Living  (APRIL)
Kate Brady, Project Manager
Human Services Research Institute (HSRI)
Amber O’Haver, Executive Director
Indiana Statewide Independent Living Council
Jay Harner, Short-term Supports & Services Supervisor & Jodie Baney , Director of Programs
Roads to Freedom Center for Independent Living
Erica McFadden, Director
Office of Independent Living Programs, Administration for Community Living
OBJECTIVES
Who are the stakeholders and important partners in your area?
Start to understand the rule and how it applies to your work.
Where do I find information on this rule?
Knowing what to do next to promote these rules or to find the information around it.
PARTNERSHIP
APRIL is working with NASILC and HSRI on the HCBS Settings Rule
CILs have been doing this work for a long time, now there is language to support our philosophy on transition
and diversion along with key partnerships we can use in our work.
Our role:
To bring awareness to our membership and IL partners on these rules
To equip CILs and SILCs with the information to increase their advocacy around transition and diversion.
To share resources with the IL field on the rules and how to educate your consumers and community.
To inform CILs and SILCs on potential partners within your state and service areas to work on issues around transition and
systems and individual advocacy.
Help identify CILs and SILCs that are doing work around this that can provide some peer mentoring for others.
HOME AND COMMUNITY-BASED SERVICES
STAKEHOLDER ENGAGEMENT
KATE BRADY, PHD ABD
PROJECT MANAGER, NCAPPS AT THE HUMAN SERVICES RESEARCH INSTITUTE
THE WHAT AND WHO OF HCBS
What are Home and Community-Based Services
(HCBS)?
HCBS provide funded support for
​:
Employment
Transportation
Homecare/home health
Medications
​ and i
n-home therapy (PT, OT, Speech,
etc.)
Housekeeping
Activities of daily living
​ such as b
athing, dressing,
toileting
​ and c
ooking
​.
Finances
Assistive Technology and Home Modifications
Who receives HCBS?
 In 2018 more than 4.7 million
people received Medicaid-funded
HCBS
 Each state has its own system and
decides to which populations they
will offer HCBS waivers
5
SETTINGS RULE:
WHERE IT CAME FROM AND WHERE IT’S GOING
People living in community-based settings were often living a life that is closer to
institutional experience
The 2014 HCBS final rule attempts to define “community based” for the first time.
The March 17, 2023, transition period deadline for full state compliance with the
HCBS settings regulation, effective March 17, 2014, is fast approaching.
ACL & CMS remain steadfast in ensuring adherence to the tenets of the rule and
the regulatory criteria, which provide the framework for ensuring that HCBS are
truly person-centered, and the settings within which they are provided facilitate
autonomy and independence.
6
RULE REQUIRES
THAT SERVICES AND
SUPPORTS:
Are integrated in and support full access to greater community
Ensure the person receives services in the community with the
same degree of access as people not receiving federal Medicaid
funding
Provide opportunities to seek employment and work in
competitive integrated settings, engage in community life, and
control personal resources
7
WHAT MAKES A
SETTING HOME
AND
COMMUNITY-
BASED?
It is in the community and supports the person’s full access
to the community
Provides opportunities to:
seek employment in integrated settings at competitive wages
participate in community life
control personal resources
It is selected by the individual from options that include
non-disability specific settings
Ensures the right to privacy, dignity, respect, and freedom
from coercion and restraint
Facilitates individual initiative, autonomy, and independence
in making life choices
8
CORE REQUIREMENTS OF THE
CMS HCBS FINAL SETTINGS RULE (2014)
Requires every state to ensure that services meet
minimum standards for integration, access to community
life, choice, autonomy, and other important consumer
protections​
Person-centered planning
States must receive final Statewide Transition Plan approval.
All states and settings will be fully compliant with the
following regulatory settings criteria:
Privacy, dignity, respect, and freedom from coercion and restraint; and
Control of personal resources.
9
ADDITIONAL CONDITIONS: PROVIDER-
OWNED OR CONTROLLED SETTINGS
Unit is owned, rented or
occupied under a legally
enforceable agreement
Privacy, lockable doors
Choice of roommates
Freedom to furnish and
decorate
Freedom to control
one’s own
schedule/activities
Access to food at any
time
Person can have visitors
they choose
at any time
10
IN PROVIDER-OWNED OR -CONTROLLED
RESIDENTIAL SETTINGS
Person must have:
A lease or other legally enforceable agreement to protect from eviction
Privacy in their unit including entrances lockable by the person (staff have keys as
needed)
Choice of roommates
Freedom to furnish and decorate their unit
Control of their schedule and activities
Access to food at any time
Visitors at any time
Physical accessibility
Deviations from this rule (except accessibility) must be supported
by a specific assessed need and justified in the person-centered
service plan (ISP-individualized service plan)
11
A PERSON-CENTERED PLAN MUST…
Identify the strengths, preferences, needs (clinical
and support), and desired outcomes of individual
Include individually identified goals and preferences
related to relationships, community participation,
employment, income and savings, healthcare and
wellness, education and others
Reflect what is important to the individual to ensure
delivery of services in a manner reflecting personal
preferences and ensuring health and welfare
Identify risk factors and plans to minimize them
Be understood by the individual
Reflect cultural considerations
12
IMPORTANCE OF PUBLIC ENGAGEMENT
ACL works closely with CMS to implement the Settings Rule
The Rule is a key to engaging community members in the
development, provision, and oversight of HCBS programs.
For the first time, ACL is specifically funding public engagement
efforts.
13
OPPORTUNITIES FOR ENGAGEMENT
Now
Statewide Transition Plans
View STPs:
https://www.medicaid.gov/medicaid/home-
community-based-services/statewide-
transition-plans/index.html
 
Heightened Scrutiny Packages:
CMS Site Visits
ACL Stakeholder calls
In the future
Corrective Action Plans
- States must be able to show that their policies
and procedures reflect the settings criteria and
they have made efforts to implement the criteria
to the fullest extent possible and work with CMS
on a concrete, time-limited plan to come into full
compliance with remaining criteria.
Waiver Amendments and Renewals
14
OPPORTUNITIES FOR ENGAGEMENT CTD
Statewide Transition
Plans
Heightened Scrutiny
Packages:
CMS Site Visits
ACL Stakeholder
calls
Corrective Action
Plans
Waiver Amendments
and Renewals
15
WHERE ARE THE STAKEHOLDERS?
16
ENGAGEMENT ACTIVITIES
17
REVIEW:
ALL HCBS
SETTINGS
MUST
Be integrated in and support full access to
community
Be selected by the individual from among setting
options;
Ensure individual rights of privacy, dignity and
respect, and freedom from coercion and
restraint;
Optimize autonomy and independence in making
life choices; and
Facilitate choice regarding services and who
provides them
Provider owned or controlled settings have
additional obligations
Any modification of these conditions must be
supported by a specific assessed need and
justified in the Person-Centered Plan (PCP)
18
KEY TAKEAWAYS
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https://www.medicaid.gov/medicaid/home-community-based-
services/downloads/hcbs-settings-rule-imp.pdf
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19
TO RECEIVE FEDERAL HCBS REIMBURSEMENT BEYOND MARCH 17,
2023, STATES MUST
20
CRITERIA THAT MUST BE MET BY 3/17/23 (NO EXCEPTIONS)
NOT IMPACTED BY PHE
Criteria not impacted by PHE, including:
– Privacy, dignity, respect, and freedom from coercion and restraint; and
– Control of personal resources.
All states and provider-owned and controlled residential settings.
 A lease or other legally enforceable agreement providing similar protections;
Privacy in their unit
Access to food and visitors at any time;  and
PCS plan documentation of modifications to Rule
21
STATES MUST SUBMIT TO CMS BY 1/1/23
Description of oversight systems 
(licensure and certification,
standards, provider manuals, person-centered plan monitoring by case
managers, etc.) have been modified to comply;
Description of assessment process 
for initial compliance and ongoing
compliance*; and
Description of a beneficiary’s recourse 
to notify state of provider
non-compliance (grievance process, notification of case manager, etc.) and
how state will address beneficiary feedback.
22
STATEWIDE TRANSITION PLAN STATUS AS OF
AUGUST 2, 2022
23
CMS WILL
AUTHORIZE
CAPS TO
INCLUDE:
24
CORRECTIVE
ACTION PLANS
(STATE
FLEXIBILITIES)
HEIGHTENED
SCRUTINY
PROCESS
26
STATE INDEPENDENT LIVING COUNCILS
(SILCS)
EMBRACING THE SPOOKY HCBS SETTING RULE 
AMBER O’HAVER, EXECUTIVE DIRECTOR 
INDIANA STATEWIDE INDEPENDENT LIVING COUNCIL 
THE HCBS SETTINGS RULE: THE ROLE OF SILCS
Building & Bridging Partnerships or Collaborations
State Agencies
State Advocacy Entities
Consumer-Directed Entities or Groups
Information Dissemination & Educational Awareness
To CILs
To Consumers & Peers with Disabilities
THE HCBS SETTINGS RULE: THE ROLE OF SILCS CTD
Systems Advocacy
Engaging in Current Advocacy Opportunities
Leading & Directing Advocacy Opportunities
Consumer Engagement
Recruitment
Empowerment
Leverage SILC Privilege & Platform
THE HCBS SETTINGS RULE: CURRENT SILC FOCUS
Does Your State Have A FINAL Approved HCBS State Transition Plan (STP)?
www.hcbsadvocacy.org
Ask your DSE and / or Other State Agency Folks
Request A Copy of the STP
Review HCBS STP
How does your State plan to enforce The Rule and ensure the rights of our peers with disabilities are upheld?
Is there a clear and transparent consumer grievance process / procedures?
Is there a Corrective Action Plan process / procedures for facilities?
How does your STP address any needed consumer transitions? Process / Procedures?
How does your STP address issues of equity? 
THE HCBS SETTINGS RULE: CURRENT SILC FOCUS CTD
Review Other State Plans – How Do These Address The Rule? Equitable Lens?
State Plan for Independent Living (SPIL)
DD Council 5-Year Strategic Plan
WIOA State Plan
Priorities & Objectives (P&Os) of State Protection & Advocacy (P&A) Services State Entity
State Plan on Aging (Indiana)
Other State Plans that are applicable???
THE HCBS SETTINGS RULE: FUTURE SILC FOCUS
SPIL 2025 – 2027 Development (Other Plans and P&Os?)
Leverage SILC seat on State Commission on Rehabilitation
Host / Conduct (with Partners) Education & Training Events for Peers with Disabilities on
Their Rights in Accordance with The Rule
What is The Rule & its Purpose?
Why is it needed?
How does it apply to & impact me as a consumer?
Examples of Violations of The Rule
What do I do if my rights are violated?
Engagement of Consumers / Peers with Disabilities in ensuring compliance with The Rule?
CONTACT
Sierra Royster, Director of Innovation, APRIL
sroyster@april-rural.org
919-346-3282
Kathy Cooper, Chair, NASILC Board
Kathy.cooper@silck.org
Amber O’Haver, Vice Chair, NASILC Board
aohaver@insilc.org
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Explore the HCBS Settings Rule and stakeholder partnerships involving organizations like APRIL, NASILC, and HSRI. Learn about the objectives, stakeholders, and key partnerships in the Home and Community-Based Services sector. Understand the importance of HCBS in providing support services like employment, transportation, and homecare. Discover the origins and implications of the HCBS settings rule and how it impacts individuals receiving services.

  • HCBS Settings Rule
  • Stakeholder Partnerships
  • Home and Community-Based Services
  • APRIL
  • NASILC

Uploaded on Sep 28, 2024 | 1 Views


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  1. SCARY OR NOT SCARY: UNDERSTANDING HCBS SETTINGS RULE Sierra Royster, Director of Innovation Association of Programs for Rural Independent Living (APRIL) Kate Brady, Project Manager Human Services Research Institute (HSRI) Amber O Haver, Executive Director Indiana Statewide Independent Living Council Jay Harner, Short-term Supports & Services Supervisor & Jodie Baney , Director of Programs Roads to Freedom Center for Independent Living Erica McFadden, Director Office of Independent Living Programs, Administration for Community Living

  2. OBJECTIVES Who are the stakeholders and important partners in your area? Start to understand the rule and how it applies to your work. Where do I find information on this rule? Knowing what to do next to promote these rules or to find the information around it.

  3. PARTNERSHIP APRIL is working with NASILC and HSRI on the HCBS Settings Rule CILs have been doing this work for a long time, now there is language to support our philosophy on transition and diversion along with key partnerships we can use in our work. Our role: To bring awareness to our membership and IL partners on these rules To equip CILs and SILCs with the information to increase their advocacy around transition and diversion. To share resources with the IL field on the rules and how to educate your consumers and community. To inform CILs and SILCs on potential partners within your state and service areas to work on issues around transition and systems and individual advocacy. Help identify CILs and SILCs that are doing work around this that can provide some peer mentoring for others.

  4. HOME AND COMMUNITY-BASED SERVICES STAKEHOLDER ENGAGEMENT KATE BRADY, PHD ABD PROJECT MANAGER, NCAPPS AT THE HUMAN SERVICES RESEARCH INSTITUTE

  5. THE WHAT AND WHO OF HCBS What are Home and Community-Based Services (HCBS)? HCBS provide funded support for : Employment Transportation Homecare/home health Who receives HCBS? In 2018 more than 4.7 million people received Medicaid-funded HCBS Each state has its own system and decides to which populations they will offer HCBS waivers Medications and in-home therapy (PT, OT, Speech, etc.) Housekeeping Activities of daily living such as bathing, dressing, toileting and cooking . Finances Assistive Technology and Home Modifications 5

  6. SETTINGS RULE: WHERE IT CAME FROM AND WHERE IT S GOING People living in community-based settings were often living a life that is closer to institutional experience The 2014 HCBS final rule attempts to define community based for the first time. The March 17, 2023, transition period deadline for full state compliance with the HCBS settings regulation, effective March 17, 2014, is fast approaching. ACL & CMS remain steadfast in ensuring adherence to the tenets of the rule and the regulatory criteria, which provide the framework for ensuring that HCBS are truly person-centered, and the settings within which they are provided facilitate autonomy and independence. 6

  7. Are integrated in and support full access to greater community RULE REQUIRES THAT SERVICES AND SUPPORTS: Ensure the person receives services in the community with the same degree of access as people not receiving federal Medicaid funding Provide opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources 7

  8. It is in the community and supports the persons full access to the community Provides opportunities to: WHAT MAKES A SETTING HOME AND COMMUNITY- BASED? seek employment in integrated settings at competitive wages participate in community life control personal resources It is selected by the individual from options that include non-disability specific settings Ensures the right to privacy, dignity, respect, and freedom from coercion and restraint Facilitates individual initiative, autonomy, and independence in making life choices 8

  9. CORE REQUIREMENTS OF THE CMS HCBS FINAL SETTINGS RULE (2014) Requires every state to ensure that services meet minimum standards for integration, access to community life, choice, autonomy, and other important consumer protections Person-centered planning States must receive final Statewide Transition Plan approval. All states and settings will be fully compliant with the following regulatory settings criteria: Privacy, dignity, respect, and freedom from coercion and restraint; and 9 Control of personal resources.

  10. ADDITIONAL CONDITIONS: PROVIDER- OWNED OR CONTROLLED SETTINGS Unit is owned, rented or occupied under a legally enforceable agreement Privacy, lockable doors Freedom to furnish and decorate Choice of roommates Freedom to control one s own schedule/activities Person can have visitors they choose at any time Access to food at any time 10

  11. IN PROVIDER-OWNED OR -CONTROLLED RESIDENTIAL SETTINGS Person must have: A lease or other legally enforceable agreement to protect from eviction Privacy in their unit including entrances lockable by the person (staff have keys as needed) Choice of roommates Freedom to furnish and decorate their unit Control of their schedule and activities Access to food at any time Visitors at any time Physical accessibility Deviations from this rule (except accessibility) must be supported by a specific assessed need and justified in the person-centered service plan (ISP-individualized service plan) 11

  12. A PERSON-CENTERED PLAN MUST Identify the strengths, preferences, needs (clinical and support), and desired outcomes of individual Include individually identified goals and preferences related to relationships, community participation, employment, income and savings, healthcare and wellness, education and others Reflect what is important to the individual to ensure delivery of services in a manner reflecting personal preferences and ensuring health and welfare Identify risk factors and plans to minimize them Be understood by the individual Reflect cultural considerations 12

  13. IMPORTANCE OF PUBLIC ENGAGEMENT ACL works closely with CMS to implement the Settings Rule The Rule is a key to engaging community members in the development, provision, and oversight of HCBS programs. For the first time, ACL is specifically funding public engagement efforts. 13

  14. OPPORTUNITIES FOR ENGAGEMENT Now In the future Statewide Transition Plans Corrective Action Plans - States must be able to show that their policies and procedures reflect the settings criteria and they have made efforts to implement the criteria to the fullest extent possible and work with CMS on a concrete, time-limited plan to come into full compliance with remaining criteria. View STPs: https://www.medicaid.gov/medicaid/home- community-based-services/statewide- transition-plans/index.html Heightened Scrutiny Packages: CMS Site Visits Waiver Amendments and Renewals ACL Stakeholder calls 14

  15. 1 2 3 4 Heightened Scrutiny Packages: CMS Site Visits ACL Stakeholder calls Statewide Transition Plans Corrective Action Plans Waiver Amendments and Renewals 15

  16. WHERE ARE THE STAKEHOLDERS? ADVOCACY GROUPS: Parent Groups Sibling groups Self-advocate groups. INDIVIDUAL PEOPLE WITH DISABILITIES THEIR FAMILIES, AND NEIGHBORS PROTECTION FROM HARM RESOURCES: State P&A Ombudsman Adult Protective Services CENTERS FOR INDEPENDENT LIVING & STATEWIDE INDEPENDENT LIVING COUNCILS 16

  17. ENGAGEMENT ACTIVITIES Show up Show up and give in person public comment Submit Submit written comments Coordinate Coordinate templates for others to use in submitting comments. Consult Consult partners about submitting joint comments Call Support Support someone receiving services to be aware of their rights and decipher if those rights are being violated. Call your legislators and other elected officials 17

  18. Be integrated in and support full access to community Be selected by the individual from among setting options; REVIEW: ALL HCBS SETTINGS MUST Ensure individual rights of privacy, dignity and respect, and freedom from coercion and restraint; Optimize autonomy and independence in making life choices; and Facilitate choice regarding services and who provides them Provider owned or controlled settings have additional obligations Any modification of these conditions must be supported by a specific assessed need and justified in the Person-Centered Plan (PCP) 18

  19. KEY TAKEAWAYS March 17th, 2023, is the deadline for state compliance. States advised to seek CMS final approval of transition plan by July 31, 2022 https://www.medicaid.gov/medicaid/home-community-based- services/downloads/hcbs-settings-rule-imp.pdf PHE exception requires corrective action plan CAPs due January 1, 2023 Continued CMS heightened scrutiny reviews for presumptively institutional settings that state claims comply. Many States under-identify these settings. Plans complex often missing required data work in coalition. 19

  20. TO RECEIVE FEDERAL HCBS REIMBURSEMENT BEYOND MARCH 17, 2023, STATES MUST Receive final Statewide Transition Plan approval (advised by 7/31/22) Comply with all settings criteria NOT directly impacted by PHE disruptions, including PHE-related workforce challenges. (CAP due 1/1/23) Time-limited CAPs available to states to authorize extension for criteria directly impacted by PHE States must document their efforts to meet these requirements, to the fullest extent possible and comply with all other settings criteria. 20

  21. CRITERIA THAT MUST BE MET BY 3/17/23 (NO EXCEPTIONS) NOT IMPACTED BY PHE Criteria not impacted by PHE, including: Privacy, dignity, respect, and freedom from coercion and restraint; and Control of personal resources. All states and provider-owned and controlled residential settings. A lease or other legally enforceable agreement providing similar protections; Privacy in their unit Access to food and visitors at any time; and PCS plan documentation of modifications to Rule 21

  22. STATES MUST SUBMIT TO CMS BY 1/1/23 Description of oversight systems (licensure and certification, standards, provider manuals, person-centered plan monitoring by case managers, etc.) have been modified to comply; Description of assessment process for initial compliance and ongoing compliance*; and Description of a beneficiary s recourse to notify state of provider non-compliance (grievance process, notification of case manager, etc.) and how state will address beneficiary feedback. 22

  23. STATEWIDE TRANSITION PLAN STATUS AS OF AUGUST 2, 2022 23

  24. Access to the broader community; Opportunities for employment; CMS WILL AUTHORIZE CAPS TO INCLUDE: Option for a private unit and/or choice of a roommate; Choice of non-disability specific settings CAPS MUST BE Concrete and limited (CMS did not set deadline) Show that policies reflect the rule; Show efforts to bring providers into compliance and to overcome PHE and provider barriers; and Show efforts to comply with rule to the fullest extent possible. 24

  25. CMS will authorize CAPs to continue federal reimbursement of HCBS beyond the end of the transition period, if states need additional time to ensure full provider compliance with the regulatory criteria NOT mentioned above. For example: Option for a private unit and/or choice of a roommate; and Access to the broader community; Opportunities for employment; Choice of non-disability specific settings. CORRECTIVE ACTION PLANS (STATE FLEXIBILITIES) States must be able to show that their policies and procedures reflect the settings criteria and they have made efforts to implement the criteria, to the fullest extent possible and work with CMS on a concrete, time-limited plan to come into full compliance with remaining criteria. States should seek stakeholder input when developing CAPs.

  26. States urged to allow public comment on evidentiary packet; States must submit evidentiary packet to CMS that demonstrates compliance with every aspect of the rule; HEIGHTENED SCRUTINY PROCESS CMS will select a sample of settings, the size informed by whether the state has submitted an assessment tool that fully assesses each of the settings rule criteria. CMS will ask state to respond to questions; CMS works with the state to determine ability to add a settings compliance into the CAP. 26

  27. STATE INDEPENDENT LIVING COUNCILS (SILCS) EMBRACING THE SPOOKY HCBS SETTING RULE AMBER O HAVER, EXECUTIVE DIRECTOR INDIANA STATEWIDE INDEPENDENT LIVING COUNCIL

  28. THE HCBS SETTINGS RULE: THE ROLE OF SILCS Building & Bridging Partnerships or Collaborations State Agencies State Advocacy Entities Consumer-Directed Entities or Groups Information Dissemination & Educational Awareness To CILs To Consumers & Peers with Disabilities

  29. THE HCBS SETTINGS RULE: THE ROLE OF SILCS CTD Systems Advocacy Engaging in Current Advocacy Opportunities Leading & Directing Advocacy Opportunities Consumer Engagement Recruitment Empowerment Leverage SILC Privilege & Platform

  30. THE HCBS SETTINGS RULE: CURRENT SILC FOCUS Does Your State Have A FINAL Approved HCBS State Transition Plan (STP)? www.hcbsadvocacy.org Ask your DSE and / or Other State Agency Folks Request A Copy of the STP Review HCBS STP How does your State plan to enforce The Rule and ensure the rights of our peers with disabilities are upheld? Is there a clear and transparent consumer grievance process / procedures? Is there a Corrective Action Plan process / procedures for facilities? How does your STP address any needed consumer transitions? Process / Procedures? How does your STP address issues of equity?

  31. THE HCBS SETTINGS RULE: CURRENT SILC FOCUS CTD Review Other State Plans How Do These Address The Rule? Equitable Lens? State Plan for Independent Living (SPIL) DD Council 5-Year Strategic Plan WIOA State Plan Priorities & Objectives (P&Os) of State Protection & Advocacy (P&A) Services State Entity State Plan on Aging (Indiana) Other State Plans that are applicable???

  32. THE HCBS SETTINGS RULE: FUTURE SILC FOCUS SPIL 2025 2027 Development (Other Plans and P&Os?) Leverage SILC seat on State Commission on Rehabilitation Host / Conduct (with Partners) Education & Training Events for Peers with Disabilities on Their Rights in Accordance with The Rule What is The Rule & its Purpose? Why is it needed? How does it apply to & impact me as a consumer? Examples of Violations of The Rule What do I do if my rights are violated? Engagement of Consumers / Peers with Disabilities in ensuring compliance with The Rule?

  33. CONTACT Sierra Royster, Director of Innovation, APRIL sroyster@april-rural.org 919-346-3282 Kathy Cooper, Chair, NASILC Board Kathy.cooper@silck.org Amber O Haver, Vice Chair, NASILC Board aohaver@insilc.org

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