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Indiana State Department of Health

ISDH Home > Health Care Quality & Regulatory > Acute Care/Hospitals > Hospital (general) Licensing and Certification Program Hospital (general) Licensing and Certification Program

Program Overview

A hospital is a health care facility that generally is an institution, a place, a building, or an agency that holds out to the general public that it is operated for hospital purposes and that it provides care, accommodations, facilities, and equipment, in connection with the services of a physician, to individuals who may need medical or surgical services.

Any facility that meets the definition of a hospital found in Indiana Code 16-18-2-179 must be licensed by the Indiana State Department of Health (ISDH) on an annual basis.

The ISDH monitors the health care quality of hospitals through the licensure process.  ISDH surveyors visit hospitals annually for licensure inspections or more often if complaints are filed about a hospital.

Announcements / Current News

 

Contact the Program

Indiana State Department of Health
Division of Acute Care
2 North Meridian Street, 4A
Indianapolis, IN 46204
(317) 233-7474 (Acute Care Receptionist)
(317) 233-1325 (ISDH Main Switchboard)
Map

Program Manager
John Lee
jlee@isdh.in.gov
(317) 233-7487
(317) 233-7472  [Administrative Assistant]

Report a Complaint or Incident to the ISDH

Report a complaint regarding a health care facility
Individuals can call or email to make complaints about care provided at any licensed or certified Indiana health care providers or suppliers.

Report an incident regarding a health care facility
The Incident Report Form is for health care facilities to notify the Indiana State Department of Health of a reportable incident pursuant to the ISDH Reportable Unusual Occurrence Policy.  The Incident Report Form is also for health care facility staff (nursing homes, intermediate care facilities, and hospice agencies) to report a reasonable suspicion of a crime against a resident pursuant to Federal regulations.  This form is not to be used to file a complaint.

Consumer Information

Your Medicare Rights and Responsibilities

Advance Directives Resource Center

Consumer Reports

Choosing a Hospital
A guide for people with Medicare

Hospital Consumer Reports

National Hospital Reporting Initiative (Hospital Compare)

Directories

Directory of Hospitals (City/County)

Directory of Hospitals (Alphabetical)

Employment Opportunities

Learn more about Employment Opportunities with the Indiana State Department of Health

Forms

Annual Non-profit Hospital Community Benefit Statement Form

Application for Construction Permit for Acute Care Facilities

Application for License to Operate a Hospital

Centers of Medicare and Medicaid Services Forms

Federal Forms Home Page

State Forms Catalog

Laws and Regulations

Federal Laws and Regulations

42 CFD 412 (Hospitals – Rehabilitation/ Psychiatric)

42 CFR 482 (General Acute Hospitals)

State Operations Manual  Appendix A (Hospitals)

42 CFR 485 (Critical Access Hospitals)

State Operations Manual  Appendix W (Critical Access Hospitals)

42 CFR 489 (Patient Dumping)

State Operations Manual  Appendix V (Patient Dumping)

Code of Federal Regulations (CFR) Homepage

State Operations Manual  Appendix T (Swing Bed)

State Laws and Rules

Indiana Code 16-21-2; Licensure of Hospitals

Indiana Code 16-21-6;  Hospital Financial Disclosure Rule

Indiana Code 16-21-9;  Provision of Charitable Care by Non-profit Hospitals

410 IAC 15-1.1; Licensure of Hospitals

410 IAC 15-1.4-2.2; Hospital Medical Error Reporting

410 IAC 15-4-1; Reporting of Healthcare Associated Infections

Indiana Law and Rules Homepage

Indiana Register

Limited Criminal History Search

Links

Professional Organizations

American Health Information Management Association

Association of Professionals in Infection Control and Epidemiology

Centers for Medicare and Medicaid Services

Indiana State Medical Association

Indiana State Nurses Association

Accreditation Organizations

American Osteopathic Association

Joint Commission on Accreditation of Hospital Organizations

Quality Improvement Organizations

Quality Improvement Organization Information

A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare.  QIOs work under the direction of the Centers for Medicare and Medicaid Services (CMS) to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries of the Medicare Trust Fund.

State Government

Indiana Public Access Counselor

Office of Medicaid Policy and Planning (FSSA)

Community Benefit Planning

Federal Government

National Government Services

Agency for Healthcare Research and Quality (AHRQ)

Americans with Disabilities Act (ADA)

Centers for Disease Control and Prevention (CDC)

Centers for Medicare and Medicaid Services (CMS)
 
Health Care Excel (HCE)

National Patient Safety Foundation

Office of Civil Rights

Program Information and Policies

American Institute of Architects' Guidelines for Design and Construction of Health Care Facilities,2001 Edition   

Centers for Medicare and Medicaid Services Letter (S&C 05-20)
 Independent Associated Deficiency Citations

Construction Plan Review for Hospitals

Submitting the Hospital Fiscal, Service and Community Benefit Reports via the Web

Advisory Letters

2014

  • AC 2014-01 HOSP Patient Self Referral to Hospital Physical Therapy Departments

2012

  • AC 2012-01 HOSP   Cardiographic Technicians and Cardiovascular Technologist Scope of Practice

2011

  • AC 2011-01 HOSP   Standing Waiver for Electronic Verification of Licensure, CSR Registration and DEA Registration
  • AC 2011-02 HOSP   Vein Harvesting by Certified Surgical First Assistants versus Certified Surgical Technologists
  • HAI-2011-01   Healthcare Associated Infections Reporting Rule

Reports

Hospital Fiscal Reports

Hospital Service Reports

Hospital Medicare Cost Reports

Hospital Audited Financial Statements

Hospital Community Benefit Reports

Medical Errors Reports

Public, Hospital Discharge Data