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                            Indiana State Department of Health
                            HOSPITAL CONSUMER REPORT
                          Report Created on: 04/24/2008
                          Posted to the Web on: 05/07/2008
    
     Jump to: Name and addresses of off-site hospitals and services 
     Jump to: Services available 
     Jump to: Hospital Staffing 
     Jump to: Third party reimbursement 
     Jump to: State licensure survey results 
     Jump to: Complaint surveys with substantiated findings 
     Jump to: Hospital accreditation status 
     Jump to: Federal Survey Table 
     Jump to: Survey history 
     Jump to: CMS Hospital Quality Alliance Quality Measures
 

 The above section lists one hospital as the licensed hospital.  In addition to the
 licensed hospital, there may be other hospitals, agencies, or services operated 
 under the hospital license.  Some of these hospitals or services may be at off-site
 (satellite) locations away from the main hospital campus.  The following are
 hospitals, agencies, and services operated under the hospital license in addition
 to the hospital listed as the licensed hospital. 
 

 The following services are available at the licensed hospital listed above.  These
 services include services provided directly by hospital staff and services that the 
 hospital provides through contracts with outside personnel.  The listed services 
 may or may not be available at the off-site (satellite) hospitals, agencies, or 
 services operated under the hospital license.
 

 The following is the number of staff employed by the hospital to provide patient 
 care.  These numbers are reported to the ISDH by the hospital at the time of a 
 survey.  The number represents the total number of staff at the licensed hospital 
 and all satellite hospitals, agencies, and services included under the hospital 
 license.  The number is listed in full-time equivalents and does not include 
 persons contracted by the hospital to perform services. 
 

 The ISDH conducts a state licensure survey at each licensed hospital 
 approximately once per year.  The survey includes the licensed hospital and a 
 sample of off-site hospitals, agencies, or services operated under the license.  If 
 a hospital is accredited, the hospital may substitute the accreditation survey for 
 the state licensure on-site survey.  In years when an accreditation survey is 
 performed, there will not be a state licensure survey conducted by the ISDH.  If 
 deficiencies are cited on a survey, the hospital may be requested by the ISDH to 
 complete a plan of correction on how and when they will correct each deficiency 
 and who will be responsible to ensure the corrections are made and will not 
 reoccur in the future.  The plan of correction is generally submitted by the 
 hospital and reviewed by the ISDH within fifteen (15) days of the survey.
    
 The following is a summary of the three most recent state licensure surveys.  
 Accreditation surveys are not included in the table below.  To
 see a list of the deficiencies cited on the state licensure survey, click on the 
 survey date.  Note that if there were no deficiencies cited on the survey, you will 
 not be able to click on the survey date.  To read an overview of the survey 
 process, click here.
 

 Any person may file a complaint with the ISDH about a hospital.  The ISDH 
 investigates all complaints.  If in the course of the investigation a violation of 
 state or federal rules or regulations is found by surveyors, the complaint is said 
 'to be substantiated with findings.'  If the surveyor verifies the facts of the 
 complaint but finds that no violation occurred of state rules or federal 
 regulations, the complaint is said to be 'substantiated without findings.'  If 
 deficiencies are cited on a complaint survey, the hospital may be requested by the
  ISDH to complete a plan of correction on how and when they will correct each 
 deficiency and who will be responsible to ensure the corrections are made and will 
 not reoccur in the future.  The plan of correction is generally submitted by the 
 hospital and reviewed by the ISDH within fifteen (15) days of the survey.
    
 The following is a summary of the number of substantiated complaint 
 investigations for the past three years.  This only indicates whether the complaint 
 was substantiated and does not indicate whether the hospital was found in 
 compliance with state rules or federal regulations.  The survey history section 
 below will show whether or not deficiencies were found on a specific complaint 
 survey.  
 

 Indiana hospitals must be licensed by the ISDH. While the ISDH does not 
 require hospitals to be accredited, many hospitals voluntarily apply for 
 accreditation from the Joint Commission on Accreditation of Healthcare 
 Organizations (JCAHO), the American Osteopathic Association (AOA), or 
 other accreditation organizations.  Accreditation surveys are performed 
 by the accreditation association once every three years.  
  
 In order for a hospital to participate in and receive payment from the Medicare
 or Medicaid programs, it must be certified as complying with the CMS Conditions
 of Participation.  The State survey process is the primary method for achieving
 certification.  However, if a national accrediting organization, such as JCAHO,
 has and enforces standards that meet the Federal Conditions of Participation,
 CMS may grant the accreditation organization 'deeming' authority, and 'deem' 
 each accredited hospital as meeting the Medicare and Medicaid certification requirements.
 The hospital would have 'deemed status' and would not be subject to additional Medicare
 surveys by the State agency.  The following chart indicates if this hospital is 
 accredited and if the hospital accreditation is 'deemed' by CMS and ISDH.
 

 Federal Medicare certification surveys are conducted to determine hospital 
 compliance with the Federal Conditions of Participation.  For non-accredited 
 federally certified hospitals, a federal Medicare certification survey is completed 
 once every three years.  A federal certification survey may also be completed if 
 the Center for Medicare and Medicaid Services (CMS) finds the hospital to be out 
 of compliance with a federal condition of participation and CMS requests that a 
 certification survey be completed.  The table below is a summary of the most 
 recent federal certification survey.
    
 In the case of a hospital that is accredited, a hospital that meets accreditation 
 standards is deemed to have met the Federal Conditions of Participation based 
 on the accreditation survey.  In that situation, the accreditation survey replaces 
 the federal certification survey.  Accredited hospitals will therefore likely not 
 have a federal certification survey.  If the following table states 'Not 
 Applicable', this indicates that the hospital is accredited and an accreditation
  survey was performed in lieu of a federal certification survey.
 

 The following is a list of state licensure, accreditation, complaint, and federal 
 certification surveys completed at the hospital in the past three years.  If a 
 deficiency was found during a survey, you may click on the survey number to see 
 a list of the deficiencies cited on that survey.  If deficiencies are cited on a 
 survey, the hospital may be requested by the ISDH to complete a plan of 
 correction on how and when they will correct each deficiency and who will be 
 responsible to ensure the corrections are made and will not reoccur in the future.
 The plan of correction is generally submitted by the hospital and reviewed by 
 the ISDH within fifteen (15) days of the survey.
 

 Background on the HQA
    
 The Centers for Medicare and Medicaid Services (CMS) Hospital Quality Alliance 
 (HQA) is a public-private collaboration that collects and reports hospital quality 
 performance information.  This effort is intended to make critical information 
 about hospital performance accessible to the public and to inform and invigorate 
 efforts to improve quality.  Participating hospitals are voluntarily reporting the 
 data.  The goals are to promote the best medical practices associated with the 
 targeted clinical disorders, prevent or reduce further instances of these selected 
 clinical disorders, and prevent related complications.
    
 The HQA identified three medical conditions as a starter set.  The three 
 conditions are acute myocardial infarction (heart attack), heart failure, and 
 pneumonia.  Ten (10) clinical quality measures were then selected to include five 
 measures on acute myocardial infarction; two measures on heart failure; and 
 three measures on pneumonia.  Each measure represents a treatment that the 
 health care provider should follow in treating the condition.
    
 The number of measures and conditions will be expanded in the coming years.  
 Seven additional measures and one condition will be added in 2005 and five 
 additional measures will be added in 2006.
    
 Indiana Hospital Quality Alliance Data
    
 The following will link you to the Hospital Quality Alliance data for Indiana 
 hospitals.  CMS updates the Hospital Quality Alliance data quarterly.  Upon 
 receipt of updates from CMS, the data is processed and integrated into the ISDH 
 Hospital Consumer Report.  The report will state the time period covered by the 
 data.  Not all hospitals have reported data to CMS.  Additional hospitals have 
 submitted data that is currently being processed by CMS and will be included on 
 future updates.  Psychiatric, children's, rehabilitation hospitals, and critical 
 access hospitals are generally not included in the data collection.
    
 Click here for the HQA report for this hospital.
    
 For additional information on the CMS Hospital Quality Alliance and the hospital 
 quality measures, click here to go to the CMS Hospital Quality Initiative Web site.
    
 

    
    

           
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