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DocuSign Envelope ID:8E4BA2A0-F8F0-406A-A380-E6C66CCD78B4 <br /> EXHIBIT A <br /> PROVIDER'S OUTSIDE AGENCY APPLICATION <br /> Previous Year Program Results The 2015 Caregiver Survey showed 100%of repotting families observing <br /> improvements in their family member's functioning. <br /> Current Year Estimated Results The 2016 Caregiver Survey also showed 100% of reporting families <br /> observing improvements in their family member's functioning. <br /> Next Year Projected Results It is projected that the 2017 Caregiver Survey will show over 90% of <br /> reporting families observing improvements in their family member's <br /> functioning. <br /> 3. Program Activity Name Maintain Program Standards: <br /> Program administration assures that all aspects of the program are in <br /> compliance with the state rules for annual certification <br /> Program Goal The program strives for a level of excellence and maintains standards <br /> required by the State Division of Aging and Adult Services <br /> Performance Measures (While the annual caregiver survey is a good tool for measuring qualitative <br /> standards of the program, state licensure is also a measurable marker.) <br /> Charles House Association will continue to surpass the NC Standards and <br /> maintain state certification to operate as an adult day program. <br /> Previous Year Program Results Charles House received recertification by the State Division of Aging and <br /> Adult Services in July,2015 <br /> Current Year Estimated Results Charles House received recertification by the State Division of Aging and <br /> Adult Services in June,2016 <br /> Next Year Projected Results It is projected that Charles House will successfully complete recertification <br /> by the State Division of Aging and Adult Services in summer,2017 <br /> 4. Program Activity Name <br /> Program Goal <br /> Performance Measures <br /> Previous Year Program Results <br /> Current Year Estimated Results <br /> Next Year Projected Results <br /> PROGRAM INFORMATION 1/27/2017 4:52:00 PM Page 13 of 16 <br />