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Hospital (general) Licensing and Certification Program
Program Overview
A hospital is a health care facility that generally is an institution, a place, a building, or an agency that holds out to the general public that it is operated for hospital purposes and that it provides care, accommodations, facilities, and equipment, in connection with the services of a physician, to individuals who may need medical or surgical services.
Any facility that meets the definition of a hospital found in Indiana Code 16-18-2-179 must be licensed by the Indiana State Department of Health (ISDH) on an annual basis.
The ISDH monitors the health care quality of hospitals through the licensure process. ISDH surveyors visit hospitals regularly in accordance with rules under IC 16-21-1-10 for licensure inspections or more often if complaints are filed about a hospital.
Announcements / Current News
Contact the Program
Indiana State Department of Health
Division of Acute Care
2 North Meridian Street, 4A
Indianapolis, IN 46204
(317) 233-7474 (Acute Care Receptionist)
(317) 233-1325 (ISDH Main Switchboard)
Map
Program Manager
Jennifer Hembree
Jhembree@isdh.IN.gov
(317) 232-3095
(317) 233-7472 [Administrative Assistant]
Report a Complaint or Incident to the ISDH
Report a complaint regarding a health care facility
Individuals can call or email to make complaints about care provided at any licensed or certified Indiana health care providers or suppliers.
Report an incident regarding a health care facility
The Incident Report Form is for health care facilities to notify the Indiana State Department of Health of a reportable incident pursuant to the ISDH Reportable Unusual Occurrence Policy. The Incident Report Form is also for health care facility staff (nursing homes, intermediate care facilities, and hospice agencies) to report a reasonable suspicion of a crime against a resident pursuant to Federal regulations. This form is not to be used to file a complaint.
Consumer Information
Your Medicare Rights and Responsibilities
Advance Directives Resource Center
Consumer Reports
Choosing a Hospital
A guide for people with Medicare
National Hospital Reporting Initiative (Hospital Compare)
Directories
Directory of Hospitals (City/County)
Directory of Hospitals (Alphabetical)
Employment Opportunities
Learn more about Employment Opportunities with the Indiana State Department of Health
Forms
Annual Non-profit Hospital Community Benefit Statement Form
Application for Construction Permit for Acute Care Facilities
Application for License to Operate a Hospital
Centers of Medicare and Medicaid Services Forms
Laws and Regulations
Federal Laws and Regulations
42 CFD 412 (Hospitals – Rehabilitation/ Psychiatric)
42 CFR 482 (General Acute Hospitals)
State Operations Manual Appendix A (Hospitals)
42 CFR 485 (Critical Access Hospitals)
State Operations Manual Appendix W (Critical Access Hospitals)
State Operations Manual Appendix V (Patient Dumping)
Code of Federal Regulations (CFR) Homepage
State Operations Manual Appendix T (Swing Bed)
State Laws and Rules
Indiana Code 16-21-2; Licensure of Hospitals
Indiana Code 16-21-6; Hospital Financial Disclosure Rule
Indiana Code 16-21-9; Provision of Charitable Care by Non-profit Hospitals
410 IAC 15-1 Hospitals Licensure Rules with Interpretive Guidelines
410 IAC 15-1.1; Licensure of Hospitals
410 IAC 15-1.4-2.2; Hospital Medical Error Reporting
410 IAC 15-4-1; Reporting of Healthcare Associated Infections
Indiana Law and Rules Homepage
Limited Criminal History Search
Links
Professional Organizations
American Health Information Management Association
Association of Professionals in Infection Control and Epidemiology
Centers for Medicare and Medicaid Services
Indiana State Medical Association
Indiana State Nurses Association
Accreditation Organizations
American Osteopathic Association
Joint Commission on Accreditation of Hospital Organizations
Quality Improvement Organizations
Quality Improvement Organization Information
A Quality Improvement Organization (QIO) is a group of health quality experts, clinicians, and consumers organized to improve the care delivered to people with Medicare. QIOs work under the direction of the Centers for Medicare and Medicaid Services (CMS) to assist Medicare providers with quality improvement and to review quality concerns for the protection of beneficiaries of the Medicare Trust Fund.
State Government
Indiana Public Access Counselor
Office of Medicaid Policy and Planning (FSSA)
Federal Government
Agency for Healthcare Research and Quality (AHRQ)
Americans with Disabilities Act (ADA)
Centers for Disease Control and Prevention (CDC)
Centers for Medicare and Medicaid Services (CMS)
National Patient Safety Foundation
Program Information and Policies
Centers for Medicare and Medicaid Services Letter (S&C 05-20)
Independent Associated Deficiency Citations
Construction Plan Review for Hospitals
Submitting the Hospital Fiscal, Service and Community Benefit Reports via the Web
Advisory Letters
2014
- AC 2014-01 HOSP Patient Self Referral to Hospital Physical Therapy Departments
2012
- Cardiographic Technicians and Cardiovascular Technologist Scope of Practice
2011
- AC 2011-01 HOSP Standing Waiver for Electronic Verification of Licensure, CSR Registration and DEA Registration
- AC 2011-02 HOSP Vein Harvesting by Certified Surgical First Assistants versus Certified Surgical Technologists
- HAI-2011-01 Healthcare Associated Infections Reporting Rule