Hospital (general) Licensing and Certification Program
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
- Retroactive to March 6, 2020
- A blanket waiver from state rules and FGI Guidelines regarding the requirements for isolation rooms. Facilities and design firms will not be required to submit waiver requests or plan designs for converting non-isolation rooms to isolation rooms during the declared National and State COVID-19 Emergency. The ISDH hereby issues a blanket waiver applicable to all hospitals subject to the requirements of this notice.
- Retroactive to March 6, 2020
- A waiver from state rules regarding plan review of rooms converted for patient use for the duration of the state and national emergency (emergency) related to the COVID‐19 is granted under the terms of this waiver.
- Room(s) and unit(s) previously planned reviewed and approved but not in current use may be operationalized without review or inspection.
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)
(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.
Choosing a Hospital
A guide for people with Medicare
Laws and Regulations
Federal Laws and Regulations
State Laws and Rules
Quality Improvement Organizations
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.
Program Information and Policies
Centers for Medicare and Medicaid Services Letter (S&C 05-20)
Independent Associated Deficiency Citations
- AC 2020-01 HOSP COVID-19 National/State Emergency Hospital Blanket Waiver: Conversion of Standard Patient Rooms to Negative Pressure Isolation Rooms
- AC 2020-02-HOSP COVID-19 National/State Emergency Hospital Blanket Waiver: Patient Rooms
- Third Emergency Order Granting Temporary Blanket Waivers for Hospitals
- Fourth Emergency Order Amending Blanket Waiver on Negative Pressure Isolation Rooms
- AC 2019-01 HOSP Standing Waiver for Use of NFPA 101 and NFPA 99 2012 Edition
- AC 2014-01 HOSP Patient Self Referral to Hospital Physical Therapy Departments
- AC 2012-01 HOSP Cardiographic Technicians and Cardiovascular Technologist Scope of Practice
- 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