Exhibit A.docx

This is an Abuse, Neglect, and Exploitation Statement form for the HomeShare program administered by the South Carolina Department of Mental Health. The document serves as an acknowledgment and compliance verification form that trained providers must complete to document their understanding of conduct prohibited under the department's Directive on Abuse, Neglect, or Exploitation (Directive No. 885-07). The form requires the provider to certify that all household members have reviewed the directive, evidenced by their signatures on the document. Additionally, providers must acknowledge receipt of the South Carolina Department of Mental Health directive and agree to post the SLED (South Carolina Law Enforcement Division) contact poster in a prominent location within their home.

The form includes signature lines for the trained provider, a dual provider if applicable, and the HomeShare Coordinator, along with spaces for the provider's address and telephone number. This document appears to be a mandatory compliance requirement for participation in the HomeShare program and serves as written evidence that providers have been informed of and understand the protocols for reporting abuse, neglect, or exploitation of patients and clients under state guidelines.