Indiana State Department of Health

HOSPITAL (HOS) CONSUMER REPORT

Created on: 04/18/2024 Posted to the Web on: 05/01/2024 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
HOSPITAL INFORMATION
Name and address of licensed Hospital HENDRICKS REGIONAL HEALTH
1000 E MAIN ST
DANVILLE, IN 46122
Telephone (317) 745-4451
Fax (317) 745-8325
Name and address of licensee HENDRICKS COUNTY HOSPITAL
1000 EAST MAIN STREET
DANVILLE, IN 46122
Telephone
Fax
Name of administrator D. MICHELLE FENOUGHTY
Type of Ownership GOVENMENT-LOCA
Hospital license number 22-005005-1
License expiration date 06/30/2024
Type of hospital State licensed and Medicare certified
Number of set up and available total beds under hospital license 160
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.
HENDRICKS REGIONAL HEALTH/AVON 8244 E US 36 AVON, IN 46123
HENDRICKS REGIONAL HEALTH/ BROWNSBURG 1411 S GREEN ST BROWNSBURG, IN 46112
HENDRICKS REGIONAL HEALTH HIBBELN SURGERY CENTER 8244 E US 36 AVON, IN 46123
HENDRICKS REGIONAL HEALTH/PLAINFIELD 1100 SOUTHFIELD DR PLAINFIELD, IN 46168
HENDRICKS REGIONAL HEALTH/YMCA 301 SATORI PARKWAY AVON, IN 46123
HENDRICKS REGIONAL HEALTH-BROWNSBURG HOSPITAL 5492 RONALD REAGAN PARKWAY BROWNSBURG, IN 46112
   
   
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 No
Anesthesia Services Yes
Audiology No
Burn Care Unit No
Cardiac Catheterization Laboratory Yes
Cardiac - Thoracic Surgery Yes
Chemotherapy Service Yes
Chiropractic Service No
CT Scanner Yes
Dental Service No
Dietetic Service Yes
Emergency Department (Dedicated) Yes
Extracorporeal Shock Wave Lithotripter No
Gerontological Specialty Services No
Home Health Services No
Hospice No
ICU - Cardiac (Non-Surgical) Yes
ICU - Medical/Surgical Yes
ICU - Neonatal Yes
ICU - Pediatric Yes
ICU - Surgical Yes
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 No
Organ Transplant Services No
Orthopedic Surgery Yes
Outpatient Services Yes
Pediatric Services Yes
Pharmacy Yes
Physical Therapy Services Yes
Positron Emission Tomography Scan No
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 Yes
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 Yes
   
   
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 02/21/2018
Number of employees (full time equivalents) 1377
Physicians (Salaried Only) 81
Physicians - Residents 0
Physicians Assistants (PA) 11
Nurses - CRNA 0
Nurses - Practitioners 6
Nurses - Registered 250
Nurses - LPN 23
Dieticians 4
Medical Social Workers 5
Medical Laboratory Technicians 3
Medical Technologists (Lab) 8
Nuclear Medicine Technicians 2
Occupational Therapists 4
Pharmacists (Registered) 10
Physical Therapists 21
Pyschologists 0
Radiology Technologists (Diagnostic) 13
Respiratory Therapists 16
Speech Therapists 3
All Others 917
   
   
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
   
02/21/2018 Most Recent 11/30/2017 2nd Most Recent 09/20/2017 3rd Most Recent
Number of Deficiencies 4 3 0
State Average for the year of the survey (rounded to nearest whole integer.) 3
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 01/01/2023 to 12/31/2023 01/01/2022 to 12/31/2022
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)
DNV & AOA 02/27/2023 02/27/2023 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
PVU211 Complaint, License Complaint 02/22/2023
OF9711 Complaint, License Complaint 10/05/2021
SIS511 Complaint 06/09/2021
V2QV11 Complaint 05/05/2021
0ZW911 Complaint 05/05/2021
NYSD11 Complaint, License Complaint 02/19/2020
CU3211 Complaint, License Complaint 09/09/2019
YNZ111 Complaint, License Complaint 06/03/2019
   
   
LINKS AND RESOURCES
Choosing a hospital.
   
CMS Hospital Quality Initiative Website
   
Click here for and overview of the hospital survey process.
   
Resources.
   
Click here to view the legal disclaimer for hospital reports.