This government document is issued by Department of Aging for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:p5rt2izphxk&q=https://www.aging.pa.gov/organization/licensing-and-monitoring/Documents/Standard%2520Waiver%2520of%2520Regulation%2520Request%2520Form.pdf&sa=U&ved=2ahUKEwjK2dvk8K_8AhXpVKQEHa3FAiE4RhAWegQIBhAC&usg=AOvVaw3XT-3UjA-8JOhZox11cY0U