Every finding on record at Safekeeping Home Health LLC

An Emergency Preparedness Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 484.102. Survey Dates: 04/06/2026 - 04/08/2026 Active Census: 7 At this Emergency Preparedness survey, Safekeeping Home Health LLC was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 484.102. QR Completed on 04/16/2026 by A4JG

This visit was for an Initial State Licensure and Initial Medicaid survey for a Home Health provider. Survey Dates: 04/06/2026 - 04/08/2026 12 Month Unduplicated Admissions: 12 This deficiency report reflects State Findings cited in accordance with 410 IAC 17. Refer to State Form for additional State Findings. ABBREVIATIONS: SOC START OF CARE

Patient's or legal representative's signature CFR(s): 484.50(a)(2) Obtain the patient's or legal representative's signature confirming that he or she has received a copy of the notice of rights and responsibilities. This ELEMENT is not met as evidenced by: Based on record review and interview, the agency failed to maintain documentation showing the patient and/or patient’s representative was provided with a copy of rights and responsibilities for 10 of 10 clinical records reviewed (Patient #1, # 2, #3, #4, #5, #6, #7, #8, #9, #10). Findings include: Based on record review and interview, the agency failed to maintain documentation showing the patient and/or patient’s representative was provided with a copy of rights and responsibilities for 10 of 10 clinical records reviewed (Patient #1, # 2, #3, #4, #6, #7, #8, #9, #10, #11, #12). Findings include: 1. A review of the clinical record for Patient #1, SOC 10/27/2025, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 2. A review of the clinical record for Patient #2, SOC 11/26/2025, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 3. A review of the clinical record for Patient #3, SOC 02/21/2026, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 4. A review of the clinical record for Patient #4, SOC 11/08/2026, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 5. A review of the clinical record for Patient #6, SOC 11/16/2025, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 6. A review of the clinical record for Patient #7, SOC 02/21/2026, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 7. A review of the clinical record for Patient #8, SOC 11/08/2025, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 8. A review of the clinical record for Patient #9, SOC 11/27/2025, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 9. A review of the clinical record for Patient #10, SOC 10/27/2025, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 10. A review of the clinical record for Patient #11, SOC 10/27/2025, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. 11. A review of the clinical record for Patient #12, SOC 10/13/2025, failed to evidence the agency document titled “Review of Admission Documents” with the patient or patient’s representative signature was maintained to verify a copy of Patient’s Rights and Responsibilities was provided by the agency. During an interview on 04/07/2026 at 11:34 AM, the Administrator indicated the agency’s process at admission is to obtain signature for the “Patient Consent” form in the admission packet. She indicated she is not currently having the patient sign the “Review of Admission Documents” form which indicates patients received a copy of rights and responsibilities in the admission packet due to prioritizing getting the consent form signed.