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DocuSign Envelope ID: 17COF518- 9238 - 480E- 96E6- 77F FCC C2626B <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />Work Statement <br />of Complete the Work Statement Chart to describe the work to be performed. <br />This chart is used to document program activities, program goals, performance measures, <br />and actual results. (Add more rows as needed) If this is a new program, you will only <br />document the projected information. Every program is required to have AT LEAST 9 <br />Program Activity, which should be SMART (Specific, Measurable, Achievable, Relevant, and <br />Time - bound. Click on SMART Goals to learn more. <br />• Program Activities should outline major activities the agency implements to accomplish its <br />program goals. (i.e. Deliver meals to elderly /disabled residents.) <br />• Program Goal should explain what the program is trying to achieve /accomplish. Goals are <br />statements about what the program should accomplish. (i.e. Deliver 900 meals per day, <br />Monday - Friday.) <br />• Performance Measures describe how you will evaluate the degree in which you achieved <br />the stated goals. (i.e. Will track the number of meals delivered each day.) <br />• Actual Program Results use program results to indicate the actual measureable <br />achievement of goals. If goals were not met, please explain. (i.e. Delivered an average of <br />905 meals per day.) <br />Work Statement Chart for Program: Florence Gray Soltys Adult Day Health Program <br />Program Goal Maintain Adult Day Health Enrollment Census <br />Performance Measures Increase marketing strategies and program awareness <br />Previous Year Program Results 48 participants were enrolled <br />Current Year Estimated Results 49 expected enrollment <br />Next Year Projected Results 50 oroiected enrollment <br />Program Goal Prevent and/or delay institutionalization <br />Performance Measures To provide financial community resources to 80% of participants <br />Previous Year Program Results Assist with supplemental funding for families in need - provided 80% <br />and prevented or delayed institutionalization <br />Current Year Estimated Results Continue to meet the 80% <br />Next Year Projected Results I Continue to meet the 80% <br />Program Goal <br />Performance Measures <br />Previous Year Program Results <br />Current Year Estimated Results <br />Next Year Projected Results <br />Program Goal <br />Performance Measures <br />Previous Year Program Results <br />Current Year Estimated Results <br />Next Year Projected Results <br />PROGRAM INFORMATION 1/23/2018 4:21:18 PM Page 20 of 25 <br />