Hospital (general) Licensing and Certification Program

A hospital 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 IC 16-18-2-179 must be licensed by the Indiana Department of Health (IDOH).

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

Report a Complaint or Incident

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 Department of Health of a reportable incident pursuant to the IDOH 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 and Reports

Advance Directives Resource Center
Choosing a Hospital - A guide for people with Medicare
Hospital Consumer Reports
National Hospital Reporting Initiative (Hospital Compare)
Your Medicare Rights and Responsibilities

Hospital Directories and Reports

Forms

Program Information and Policies

Centers for Medicare and Medicaid Services Letter (S&C 05-20) - Independent Associated Deficiency Citations
Construction Plan Review for Hospitals
Submitting the Hospital Fiscal and Service Reports via the Web

Advisory Letters

Year	Number	Title
2020	AC-2020-02-HOSP	COVID-19 National/State Emergency Hospital Blanket Waiver: Patient Rooms
2020	AC-2020-01 HOSP	COVID-19 National/State Emergency Hospital Blanket Waiver: Conversion of Standard Patient Rooms to Negative Pressure Isolation Rooms
2020		Third Emergency Order Granting Temporary Blanket Waivers for Hospitals
2020		Fourth Emergency Order Amending Blanket Waiver on Negative Pressure Isolation Rooms
2019	AC 2019-01 HOSP	Standing Waiver for Use of NFPA 101 and NFPA 99 2012 Edition
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
2011	AC-2011-02 HOSP	Vein Harvesting by Certified Surgical First Assistants versus Certified Surgical Technologists
2011	HAI-2011-01	Healthcare Associated Infections Reporting Rule

Adding an offsite

To add an offsite to your hospital license, please submit the following documents to Program Director Jennifer Hembree.

Request on facility letterhead to add the offsite with the effective date
Indiana Department of Health healthcare engineering approval letter for the project
AIA substantial completion document
Homeland Security Construction Design release document (if a new building or changing occupancy type such as business to healthcare)
Fire inspection (this must be from the state or local fire department)

Contact the Program

Indiana Department of Health Division of Acute Care 2 North Meridian Street, 4A Indianapolis, IN 46204	Program Manager Jennifer Hembree Jhembree@health.IN.gov
Acute Care Receptionist: 317-233-7474 IDOH Main Switchboard: 317-233-1325	317-232-3095 Administrative Assistant: 317-233-7472

Laws and Regulations

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)
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)
National Patient Safety Foundation
Office of Civil Rights