I have already provided a number of specific comments, and I have one more that I do not know how to precisely address in regulation.  The concern is that respite hours are not adequately contriolled by the individual.  In our case we have two skilled nursing providers, and there are extensive problems with their requesting and receiving authorization for hours that we did not want them to have, and we are unable to direct proper allocation.  There is no daily/weekly/monthly accounting of the hours approved/available/worked.  We have instances where the hours approved extend beyond the authorized year, hours billed were not worked, and available hours were denied - all without recourse for the individual to approve and direct.  The commonwealth contractor, Keypro, will only talk to providers.  We are told to have the providers follow our requests, but they do not.  The commonweelth case workers no longer can take action to assist the individual.  There needs to be improved accountability and control for the individual. To a smaller extent this problem also impacts the AT and EM process.