Indiana State Department of Health
HOSPITAL (HOS) CONSUMER REPORT
               Created on: 3/7/2024
                Posted to the Web on: 3/20/2024
 
    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 

 
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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.

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 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
   

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.
   
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.