Thank you for this opportunity to offer opinion and suggestions regarding the waiver.  I am an educator who has worked with families who use the waiver.  In addition, we have a family member and a friend who need and use this important support. It always has made me proud that we offer this to our fellow Virginians who are dealing with such truly difficult situations. In reading over the provision about nursing, I was dismayed to read that there is little to no flexibility regarding the use of nursing hours.  There are instances when a regularly assigned nurse is unable to meet her work obligation due to illness or her own family emergency.  When a family has qualified for 16 hours of nursing support, it means that they need a trained nurse to insure their child's well being in school and in the evening while the family sleeps.  Families with a child with a significant health issue live very demanding and emotionally draining lives. Their children struggle with things that we all take for granted- like breathing or eating.  When a nurse is unable to work the evening shift, the parents must be on continuous duty to insure that life support machines are able to function, that medication is administered, that breathing issues are immediately dealt with, that  seizures are attended to etc, etc etc.  Of course they want to do this for their child but they have already put in a full day at work and have another facing them the next day.  With some flexibility of using the nursing hours, another nurse could be asked to come in earlier so the parent could rest. This solution is cost neutral as you are not paying for the shift of the person who was unable to come to work  but now paying the relief person for additional hours.  I think it is humane to offer parents who are dealing with a seriously compromised child the ability to rest so that they can offer the best quality of care to their child. It is also in the child's best interest to be  afforded  quality care by care givers who are rested and up to the task.  Please consider allowing flexibility in the use of the nursing hours.  It is the right thing to do.