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This page is intended to provide acute care facilities with information on the reporting of incidents to the Indiana State Department of Health (ISDH). Except where otherwise stated, this page applies to:
• Ambulatory surgery centers
• Home health agencies
• Hospice agencies
This page is not intended for consumers for the submitting of complaints about a health care facility. Consumers should go to the Reporting a complaint web page at www.in.gov/isdh/21533.htm for information on reporting a complaint.
This page is also not intended for "covered individuals" for the Reporting a reasonable suspicion of a crime against a resident. Providers should go to the Reporting a reasonable suspicion of a crime against a resident web page at www.in.gov/isdh/25766.htm for information.
Indiana State Department of Health
Division of Long Term Care
2 North Meridian Street, 4B
Indianapolis, IN 46204
(317) 233-7442 (Long Term Care Receptionist)
(317) 233-1325 (ISDH Main Switchboard)
Complaint and Incident Reporting Program Director
Director, Division Director
Phone: (317) 233-1286
Phone: (317) 233-7472 [Administrative Assistant]
Fax: (317) 233-7157
CMS: Centers for Medicare and Medicaid Services ISDH: Indiana State Department of Health
Incident Reporting System
The preferred method to report an incident is through the ISDH Incident Reporting System. The Incident Reporting System is an online system located on the ISDH Gateway at the same location as the Survey Report System. Health care facilities can access the Gateway at https://gateway.isdh.in.gov/. If a follow-up report is needed, the facility submits the follow-up report through the Incident Reporting System.
Quick Guide (provides instructions on using the Incident Reporting System)
Alternative Ways to Report Incidents
1. Email the report to the ISDH. The Incident Report Form should be used.
Email address for incident reports: firstname.lastname@example.org
2. Fax the report to the ISDH. The Incident Report Form should be used.
Fax number for incident reports: (317) 233-7494
3. Call the ISDH [not the preferred reporting method]
Complaint / Incident report line: 1-800-246-8909 [available during state business hours]
When calling the complaint / incident report line, you will be transferred to a nurse surveyor in the complaint / incident reporting program if there is an available surveyor. If there is not a surveyor available to take the call, your call will go to the report line voicemail.
Complaint / Incident report line voicemail: (317) 233-5359
If the complaint / incident report line is busy, you may call the voicemail line and leave the report on voicemail.
4. During non-state business hours, you may call the after-hours number (317) 233-8115.
If the Incident Reporting System was not used to submit a report and follow-up report is needed, the facility must submit a written follow-up report by fax (317) 233-7494 or email (email@example.com). Follow-up reports may not be submitted by telephone.
Incident Report Form
If reporting by email or fax, the Incident report form is to be used by health care facilities for the reporting of reportable incidents. This form may be used by acute care and long term care facilities, centers, agencies, or clinics to notify the ISDH of a reportable incident. The Incident report form is not to be used by covered individuals to report a reasonable suspicion of a crime against a long term care facility resident or by consumers to file a complaint.
Regardless of the method of reporting, the following information should be included when reporting a reportable incident or suspected crime against a resident. The Incident report form may be used for this purpose.
Type of report (choose one): Initial / Follow-up / Initial with Follow-up Facility name Facility address Facility city, state and zip Person making the report and their title Date and time of incident Residents involved, room number, age and diagnosis Staff involved, their title, and professional license or aide registry number Brief description of incident Type of injury/injuries Immediate action taken Preventative measures taken
State Rule: 410 IAC 15-2.2-1(d)
(d) The center shall develop, implement, and maintain a written plan to address the internal review and reporting of unusual occurrences and disasters. The plan must cover, but not be limited to, the following:
(1) Patient injuries or marked deterioration of patient condition occurring under unanticipated or unexpected circumstances.
(2) Unexplained loss of or theft of a controlled substance.
(3) Deaths occurring within the center.
State Rule: 410 IAC 15-1.2-1(e)
(e) The hospital shall report the following incidents to the division:
(1) Verbal reports within twenty-four (24) hours of occurrence on:(A) murder, suicide, or kidnapping of patient occurring after admission;
(B) reportable infection outbreaks or food poisonings as required by federal, state, and local law; and
(C) a disruption, exceeding four (4) hours, in the continued safe operation of the hospital or in the provision of patient care, caused by internal or external disasters, strikes by health care workers, or unscheduled termination of vital services.(2) Written reports on occurrences listed in subdivision (1), if requested, shall be submitted to the division within a reasonable period of time and document all information required by the department, including, but not limited to, the following:(A) An explanation of the circumstances surrounding the incident.(3) This subsection does not replace other reporting requirements. Copies of these required reports will be acceptable in satisfying subdivision (2).
(B) Summaries of all findings, conclusions, and recommendations associated with the review of the incident.
(C) A summary of actions taken to resolve identified problems, to prevent recurrence of the incident, and to improve overall patient care.
ISDH Program Policies and Procedures
•ISDH Division of Acute Care Reportable Incidents Policy [applies to hospitals]
Page Last Updated: May 8, 2014