Indiana State Department of Health

HOSPITAL (HOS) CONSUMER REPORT

Created on: 11/13/2014 Posted to the Web on: 11/26/2014 Jump to: Name and addresses of off-site hospitals and services Jump to: Services available Jump to: Hospital Staffing Jump to: State licensure survey results Jump to: Complaint surveys with substantiated findings Jump to: Third party reimbursement Jump to: Hospital accreditation status Jump to: Survey history Jump to: CMS Hospital Quality Alliance Quality Measures
HOSPITAL INFORMATION
Name and address of licensed Hospital DEARBORN COUNTY HOSPITAL
600 WILSON CREEK RD
LAWRENCEBURG, IN 47025
Telephone (812) 537-1010
Fax (812) 537-2897
Name and address of licensee DEARBORN COUNTY HOSPITAL
600 WILSON CREEK RD
DEARBORN, IN 47025
Telephone
Fax
Name of administrator ROGER HOWARD
Type of Ownership GOVENMENT-LOCA
Hospital license number 15-005077-1
License expiration date 12/31/2015
Type of hospital State licensed and Medicare certified
Number of set up and available total beds under hospital license 78
Hospital Website
 
View location on map
 
   
   
NAMES AND ADDRESSES OF ADDITIONAL HOSPITALS, AGENCIES, AND SERVICES OPERATED UNDER THE HOSPITAL LICENSE
The above section lists one hospital as the licensed hospital.  In addition to the
licensed hospital, there may be other hospitals, agencies, or services associated
with the licensed hospital under the hospital's license number or under a separate
license number.  Some of these hospitals or services may be located at sites
separate from the main hospital campus.  The following are
hospitals, agencies, and services associated with the main hospital.
DEARBORN CO HOSPITAL HOME HEALTH AND HOSPICE 370 BIELBY RD LAWRENCEBURG, IN 47025
DEARBORN CO HOSPITAL HOME HEALTH AND HOSPICE 370 BIELBY ROAD LAWRENCEBURG, IN 47025
   
   
SERVICES AVAILABLE
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.
Service
Available (Yes/No)
Alcohol and/or Drug Services Yes
Anesthesia Services Yes
Audiology No
Burn Care Unit No
Cardiac Catheterization Laboratory Yes
Cardiac - Thoracic Surgery No
Chemotherapy Service Yes
Chiropractic Service No
CT Scanner Yes
Dental Service No
Dietetic Service Yes
Emergency Department (Dedicated) Yes
Extracorporeal Shock Wave Lithotripter Yes
Gerontological Specialty Services No
Home Health Services Yes
Hospice No
ICU - Cardiac (Non-Surgical) No
ICU - Medical/Surgical Yes
ICU - Neonatal No
ICU - Pediatric No
ICU - Surgical No
Laboratory Clinical Yes
Magnetic Resonance Imaging (MRI) Yes
Neonatal Nursery Yes
Neurosurgical Services No
Nuclear Medicine Services Yes
Obstetric Service Yes
Occupational Therapy Services Yes
Operating Rooms Yes
Opthalmic Surgery Yes
Optometric Services Yes
Organ Transplant Services No
Orthopedic Surgery Yes
Outpatient Services Yes
Pediatric Services No
Pharmacy Yes
Physical Therapy Services Yes
Positron Emission Tomography Scan Yes
Post-Operative Recovery Rooms Yes
Psychiatric Services - Emergency Yes
Psychiatric - Child Adolescent No
Psychiatric - Forensic No
Psychiatric - Geriatric No
Psychiatric - Inpatient No
Psychiatric - Outpatient No
Radiology Services Diagnostic Yes
Radiology Services Therapeutic Yes
Reconstructive Surgery No
Respiratory Care Services Yes
Rehab-Inpatient (CARF ACC) Yes
Rehab-Outpatient Yes
Renal Dialysis (acute Inpatient) Yes
Social Services Yes
Speech Pathology Services Yes
Surgical Services - Inpatient Yes
Surgical Services - Outpatient Yes
Trauma Center (Certified) No
Transplant Center, Medicare Certified No
Urgent Care Center Services No
   
   
HOSPITAL STAFFING
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.
Staffing as of 06/04/2014
Number of employees (full time equivalents) 557
Physicians (Salaried Only) 4
Physicians - Residents 0
Physicians Assistants (PA) 0
Nurses - CRNA 0
Nurses - Practitioners 3
Nurses - Registered 78
Nurses - LPN 19
Dieticians 2
Medical Social Workers 3
Medical Laboratory Technicians 12
Medical Technologists (Lab) 10
Nuclear Medicine Technicians 5
Occupational Therapists 2
Pharmacists (Registered) 7
Physical Therapists 6
Pyschologists 0
Radiology Technologists (Diagnostic) 32
Respiratory Therapists 13
Speech Therapists 1
All Others 360
   
   
STATE LICENSURE SURVEYS
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 sited 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 read an overview of the survey process, click here
   
06/04/2014 Most Recent 01/30/2013 2nd Most Recent 07/20/2011 3rd Most Recent
Number of Deficiencies 0 14 0
State Average for the year of the survey (rounded to nearest whole integer.) 4 5 4
Survey Report N/A N/A N/A
   
   
SUBSTANTIATED COMPLAINTS
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.
Current Year 01/01/2013 to 12/31/2013 01/01/2012 to 12/31/2012
0 0 0
     
THIRD PARTY REIMBURSEMENT
Accepts Medicare The hospital accepts Medicare reimbursement and meets the standards that the federal government has set for the provided services. Yes
Accepts Medicaid The hospital accepts Medicaid reimbursement and meets the standards that the Indiana Office of Medicaid Policy and Planning has set for provided services. Yes
   
HOSPITAL ACCREDITATION STATUS
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.
Accreditation Organization Effective date of accreditation Expiration date of accreditation Deemed (Y/N)
AOA/HFAP 08/08/2014 08/06/2017 Yes
   
SURVEY HISTORY
 
The following is a list of state licensure, accreditation, complaint, and federal 
surveys completed at the hospital in the past five years. 
 
The survey report is not posted until the report has been provided to the facility 
and their plan of correction submitted and approved, if required.
The survey report therefore will likely not be posted until four to six weeks after the exit date.
    
In the grid below click on an event ID that is underlined to see the survey report for that event.
Event ID Type Date of Survey
6GL611 License Complaint, Complaint 09/10/2014
PYQY11 State Licensure 06/04/2014
B24411 Complaint, License Complaint 09/30/2013
K0HW11 Complaint, License Complaint 05/09/2013
97YX11 Complaint, License Complaint 01/31/2013
MKV611 State Licensure 01/30/2013
ROG311 Complaint, License Complaint 05/15/2012
W24N11 License Complaint, Complaint 11/01/2011
SH6Q11 State Licensure 07/20/2011
JD6K12 Complaint, Follow Up 02/03/2011
JD6K11 Complaint 11/17/2010
YBOP11 State Licensure 05/12/2010
   
   
CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) HOSPITAL QUALITY ALLIANCE (HQA)
 
Background on the HQA
 
The Center 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; tow 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 hospital, and critical
access hospitals are generally not included in the data collection.
 
Click here for the HQA report for this hospital.
 
Click here to go to the CMS Hospital Quality Initiative Website.
   
LINKS AND RESOURCES
Choosing a hospital. Click here for and overview of the hospital survey process. Resources. Click here to view the legal disclaimer for hospital reports.