Facility: Area: Month/Year: Indicator: Therapy Standards of Practice- Are all of the technical components required for therapy

provision present and timely? Threshold: 90% compliance # Charts audited: Directions: - On a monthly basis, 25% of the current caseload, with a minimum of 5 charts/ maximum of 10 charts must be audited. Each discipline reviewed is considered a chart. - This audit should include all payor sources and all disciplines; current and discharged within the past 45 days. - Place a 1 for a Yes; a 2 for a No; a "3" for n/a in the box to respond to the indicator. If the threshold is not reached, an action plan must be developed. Auditor Initials Patient Initials Physician's Initials Discipline Therapist Initials Payor Status Eval/tx or eval order present MD signature on order MD date on order Clarification order present Freq/duration/modalities included MD signature on order MD date on order Change in plan of care order Freq/duration/modalities included MD signature on order MD date on order D/C order present Initial mgd care referral/authorization present or noted Cont. mgd care referral/authorization present or noted Evaluation present MD signature present MD date within cert. period Monthly summary present Servs compliant with physician orders MD signature & date within cert. period Discharge summary present State documentation pressent Daily notes present Progress Reports present Supervisory treatment note/visit present at least every 10 visits Care plan documentation present Service Log Matrix Present - with signatures Current (C) or Discharged (D/C) Case * Chart audits should be conducted on Customer's Medical Chart * Comment on items that are Not Present Key: 1=Yes (item is present) 2=No (item or part of item is Not present) 3=N/A-item is not applicable. Comments/Action Plan:

Facility: Residence at Foresgate Area: 2 Territory 8 Month/Year: Indicator: Therapy Standards of Practice- Are all of the technical components required for therapy provision present and timely? Threshold: 90% compliance # Charts audited: REVISED - January 1, 2010 Directions: - On a monthly basis, 25% of the current caseload, with a minimum of 5 charts/ maximum of 10 charts must be audited. Each discipline reviewed is considered a chart. - This audit should include all payor sources and all disciplines; current and discharged within the past 45 days. - Place a 1 for a Yes; a 2 for a No; a "3" for n/a in the box to respond to the indicator. If the threshold is not reached, an action plan must be developed. Auditor Initials Patient Initials Physician's Initials Discipline Therapist Initials Payor Status Eval/tx or eval order present MD signature on order MD date on order Clarification order present Freq/duration/modalities included MD signature on order MD date on order Change in plan of care order Freq/duration/modalities included MD signature on order MD date on order D/C order present MD SF KN PT RA KN OT SL MED B 1 1 1 1 1 1 1 3 3 3 3 3 MD DF KN OT MT MED B 1 1 1 1 1 1 1 3 3 3 3 3 MD HA KN PT RA MED B 1 1 1 1 1 1 1 3 3 3 3 3 MD GS KN PT RA MED B 1 1 1 1 1 1 1 3 3 3 3 3 MD MQ KN KN OT PT MT RA MED B 1 1 1 1 1 1 1 3 3 3 3 3 1 1 1 1 1 1 1 3 3 3 3 3 OT SL MD BC KN PT RA MED B 1 1 1 1 1 1 1 3 3 3 3 3

10

ST CS Yes 10 10 10 10 10 10 10 0 0 0 0 No 0 0 0 0 0 0 0 0 0 0 0 0 n/a 0 0 0 0 0 0 0 0 0 0 0 0 Compliant Non-Compliant 100.00% 0.00% 100.00% 0.00% 100.00% 0.00% 100.00% 0.00% 100.00% 0.00% 100.00% 0.00% 100.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00%

1 1 1 1 1 1 1 3 3 3 3 3

1 1 1 1 1 1 1 3 3 3 3 3

1 1 1 1 1 1 1 3 3 3 3 3

Initial mgd care referral/authorization present or noted 3 3 3 3 3 3 3 Cont. mgd care referral/authorization present or noted 3 3 3 3 3 3 3 Evaluation present 1 1 1 1 1 1 1 MD signature present 1 1 1 1 1 1 1 MD date within cert. period 1 1 1 1 1 1 1 Monthly summary present 3 3 3 3 3 3 3 Servs compliant with physician orders 3 3 3 3 3 3 3 MD signature & date within cert. period 3 3 3 3 3 3 3 Discharge summary present 3 3 3 3 3 3 3 State documentation pressent 1 1 1 1 1 1 1 Daily notes present 1 1 1 1 1 1 1 Progress Reports present 1 1 1 1 1 1 1 Supervisory treatment note/visit present at least every 10 visits Care plan documentation present 1 1 1 1 1 1 1 Service Log Matrix Present - with signatures 1 1 2 2 2 2 2 Current (C) or Discharged (D/C) Case C C C D/C C C C * Chart audits should be conducted on Customer's Medical Chart * Comment on items that are Not Present Key: 1=Yes (item is present) 2=No (item or part of item is Not present) 3=N/A-item is not applicable. Comments/Action Plan:

3 3 1 1 1 3 3 3 3 1 1 1

3 3 1 1 1 3 3 3 3 1 1 1

3 3 1 1 1 3 3 3 3 1 1 1

0 0 10 10 10 0 0 0 0 10 10 10 0 10 2

0 0 0 0 0 0 0 0 0 0 0 0 0 8

0 0 0 0 0 0 0 0 10 0 0 0 0

0.00%

0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 0.00% 100.00% 0.00% 0.00% 0.00% 0.00% 0.00% 80.00%

100.00% 100.00% 100.00% 0.00% 0.00% 0.00% 100.00% 100.00% 100.00% 100.00% 0.00% 100.00% 20.00%

1 2 C

1 2 C

1 2 D/C