Indiana Department of Health

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.

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.

• Choosing a hospital.
• Click here for and overview of the hospital survey process.
• Links and resources.
• Click here to view the legal disclaimer for hospital reports.