CHAPTER 2. LICENSURE OF HOSPITALS
IC 16-21-2
Chapter 2. Licensure of Hospitals
IC 16-21-2-1
Application of chapter
Sec. 1. (a) Except as provided in subsection (b), this chapterapplies to all hospitals, ambulatory outpatient surgical centers,abortion clinics, and birthing centers.
(b) This chapter does not apply to a hospital operated by thefederal government.
(c) This chapter does not affect a statute pertaining to theplacement and adoption of children.
As added by P.L.2-1993, SEC.4. Amended by P.L.96-2005, SEC.5.
IC 16-21-2-2
Duty to license and regulate hospitals, ambulatory outpatientsurgical centers, birthing centers, and abortion clinics
Sec. 2. The state department shall license and regulate:
(1) hospitals;
(2) ambulatory outpatient surgical centers;
(3) birthing centers; and
(4) abortion clinics.
As added by P.L.2-1993, SEC.4. Amended by P.L.96-2005, SEC.6.
IC 16-21-2-2.5
Adoption of rules concerning birthing centers and abortion clinics
Sec. 2.5. (a) The state department shall adopt rules underIC 4-22-2 to do the following concerning birthing centers andabortion clinics:
(1) Establish minimum license qualifications.
(2) Establish the following requirements:
(A) Sanitation standards.
(B) Staff qualifications.
(C) Necessary emergency equipment.
(D) Procedures to provide emergency care.
(E) Quality assurance standards.
(F) Infection control.
(3) Prescribe the operating policies, supervision, andmaintenance of medical records.
(4) Establish procedures for the issuance, renewal, denial, andrevocation of licenses under this chapter. The rules adoptedunder this subsection must address the following:
(A) The form and content of the license.
(B) The collection of an annual license fee.
(5) Prescribe the procedures and standards for inspections.
(b) A person who knowingly or intentionally:
(1) operates a birthing center or an abortion clinic that is notlicensed under this chapter; or
(2) advertises the operation of a birthing center or an abortionclinic that is not licensed under this chapter;commits a Class A misdemeanor.
As added by P.L.96-2005, SEC.7.
IC 16-21-2-3
Determination of coverage of chapter; review
Sec. 3. The council may determine if an institution or agency iscovered by this chapter. A decision of the council under this sectionis subject to review under IC 4-21.5.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-4
Administration of chapter
Sec. 4. The state department shall administer this chapter with theadvice of the council.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-5
Hospital governing board; responsibilities
Sec. 5. The governing board of the hospital is the supremeauthority in the hospital and is responsible for the following:
(1) The management, operation, and control of the hospital.
(2) The appointment, reappointment, and assignment ofprivileges to members of the medical staff, with the advice andrecommendations of the medical staff, consistent with theindividual training, experience, and other qualifications of themedical staff.
(3) Establishing requirements for appointments to andcontinued service on the hospital's medical staff, consistent withthe appointee's individual training, experience, and otherqualifications, including the following requirements:
(A) Proof that a medical staff member has qualified as ahealth care provider under IC 16-18-2-163(a).
(B) The performance of patient care and related duties in amanner that is not disruptive to the delivery of qualitymedical care in the hospital setting.
(C) Standards of quality medical care that recognize theefficient and effective utilization of hospital resources,developed by the medical staff.
(4) Upon recommendation of the medical staff, establishingprotocols within the requirements of this chapter and 410 IAC15-1.2-1 for the admission, treatment, and care of patients withextended lengths of stay.
As added by P.L.2-1993, SEC.4. Amended by P.L.162-1999, SEC.5.
IC 16-21-2-6
Hospital governing board; disciplinary actions; reports; immunity
Sec. 6. (a) The governing board shall report, in writing, to theIndiana medical licensing board the results and circumstances of afinal, a substantive, and an adverse disciplinary action taken by thegoverning board regarding a physician on the medical staff or an
applicant for the medical staff if the action results in voluntary orinvoluntary resignation, termination, nonappointment, revocation, orsignificant reduction of clinical privileges or staff membership. Thereport shall not be made for nondisciplinary resignations or for minordisciplinary action.
(b) The governing board and the governing board's employees,agents, consultants, and attorneys have absolute immunity from civilliability for communications, discussions, actions taken, and reportsmade concerning disciplinary action or investigation taken orcontemplated if the reports or actions are made in good faith andwithout malice.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-7
Medical staff; responsibilities
Sec. 7. The medical staff of a hospital is responsible to thegoverning board for the following:
(1) The clinical and scientific work of the hospital.
(2) Advice regarding professional matters and policies.
(3) Review of the professional practices in the hospital for thepurpose of reducing morbidity and mortality and for theimprovement of the care of patients in the hospital, includingthe following:
(A) The quality and necessity of care provided.
(B) The preventability of complications and deaths occurringin the hospital.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-8
Retrospective medical review; medical staff committee members;immunity
Sec. 8. The members of a medical staff committee who conducta retrospective medical review have absolute immunity from civilliability for the following:
(1) Communications made in committee meetings.
(2) Reports and recommendations made by the committeearising from deliberations by the committee to the governingboard of the hospital or another duly authorized medical staffcommittee.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-9
Practice of medicine not authorized by chapter; performance ofhealth care services not prohibited
Sec. 9. This chapter does not authorize a person or a state, county,or local governmental unit, division, department, board, or agency toengage in the practice of medicine. However, this chapter does notprohibit the performance of health care services by a hospitalemployee in a hospital when that performance is delegated orordered by a licensed health practitioner if the services performed are
within the practitioner's scope of practice.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-10
Necessity of license
Sec. 10. A:
(1) person;
(2) state, county, or local governmental unit; or
(3) division, a department, a board, or an agency of a state,county, or local governmental unit;
must obtain a license from the state health commissioner underIC 4-21.5-3-5 before establishing, conducting, operating, ormaintaining a hospital, an ambulatory outpatient surgical center, anabortion clinic, or a birthing center.
As added by P.L.2-1993, SEC.4. Amended by P.L.96-2005, SEC.8.
IC 16-21-2-11
License; application; form; information
Sec. 11. (a) An applicant must submit an application for a licenseon a form prepared by the state department showing that:
(1) the applicant is of reputable and responsible character;
(2) the applicant is able to comply with the minimum standardsfor a hospital, an ambulatory outpatient surgical center, anabortion clinic, or a birthing center, and with rules adoptedunder this chapter; and
(3) the applicant has complied with section 15.4 of this chapter.
(b) The application must contain the following additionalinformation:
(1) The name of the applicant.
(2) The type of institution to be operated.
(3) The location of the institution.
(4) The name of the person to be in charge of the institution.
(5) If the applicant is a hospital, the range and types of servicesto be provided under the general hospital license, including anyservice that would otherwise require licensure by the statedepartment under the authority of IC 16-19.
(6) Other information the state department requires.
As added by P.L.2-1993, SEC.4. Amended by P.L.12-1994, SEC.10;P.L.162-1999, SEC.6; P.L.96-2005, SEC.9.
IC 16-21-2-11.5
Construction projects; prior notice and hearing
Sec. 11.5. (a) As used in this section, "construction project"means the erection, installation, alteration, repair, or remodeling ofa building or structure that, when completed, will be subject tolicensure as a hospital or an ambulatory outpatient surgical centerunder this article. The term does not include the acquisition orinstallation of medical equipment or the purchase of the services ofan architect, engineer, or consultant to prepare plans or studiesrelated to a construction project. (b) Except as provided in subsection (c), this section applies to ahospital or an ambulatory outpatient surgical center for whichlicensure is required under this article.
(c) This section does not apply to:
(1) a hospital or an ambulatory outpatient surgical center that isoperated by the federal government or an agency of the federalgovernment; or
(2) a construction project begun before July 1, 2005.
For purposes of this subsection, a construction project is consideredto have begun on the day that the physical erection, installation,alteration, repair, or remodeling of the building or structurecommences.
(d) Before the owner of:
(1) a hospital or proposed hospital may begin a constructionproject that is estimated by the owner to cost at least ten milliondollars ($10,000,000); or
(2) an ambulatory outpatient surgical center or a proposedambulatory outpatient surgical center may begin a constructionproject that is estimated by the owner to cost at least threemillion dollars ($3,000,000);
the owner shall hold at least two (2) public hearings concerning theconstruction project and publish notice of each hearing at least ten(10) days before the hearing is held.
(e) A notice published under subsection (d) must meet thestandards specified for public notices in IC 5-3-1.
(f) A hearing held under subsection (d):
(1) must:
(A) be held at a location not more than ten (10) miles fromthe site of the construction project;
(B) be held exclusively by the owner or the owner'srepresentative; and
(C) include an announcement from the owner or the owner'srepresentative that provides to the public:
(i) a description of;
(ii) an estimate of the cost of; and
(iii) a statement regarding the owner's reason for;
the construction project, including a description of the healthcare services that will be provided by the hospital orambulatory outpatient surgical center as a result of theconstruction project; and
(2) may be held:
(A) on any day of the week other than Saturday or Sunday;and
(B) at any time not earlier than 3 p.m. or later than 9 p.m.;
as determined by the owner.
(g) A hearing held as required under this section does not causeany information or materials possessed or held by the owner or theowner's employee, contractor, agent, or representative to bediscoverable or considered public information or public materials.
(h) A statement or question concerning a construction project, or
an objection to a construction project, that arises during a hearingheld under this section may not cause a delay in or denial of theissuance of a license under this article.
(i) Compliance with this section may be enforced only by the statedepartment.
As added by P.L.67-2005, SEC.2.
IC 16-21-2-12
License; application; fee
Sec. 12. An application must be accompanied by a licensing feeat the rate adopted by the council under IC 4-22-2.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-13
License; issuance
Sec. 13. The state health commissioner may:
(1) issue a license upon the application without furtherevidence; or
(2) request additional information concerning the applicationand conduct an investigation to determine whether a licenseshould be granted.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-14
License; duration; transferability; posting; renewal
Sec. 14. A license to operate a hospital, an ambulatory outpatientsurgical center, an abortion clinic, or a birthing center:
(1) expires one (1) year after the date of issuance;
(2) is not assignable or transferable;
(3) is issued only for the premises named in the application;
(4) must be posted in a conspicuous place in the facility; and
(5) may be renewed each year upon the payment of a renewalfee at the rate adopted by the council under IC 4-22-2.
As added by P.L.2-1993, SEC.4. Amended by P.L.96-2005, SEC.10.
IC 16-21-2-15
Physician to be on duty at all times at hospital with at least 100beds
Sec. 15. A hospital with at least one hundred (100) beds shallhave on duty at all times at least one (1) physician licensed underIC 25-22.5. Implementation of this section shall be subject to rulespromulgated by the state department of health to ensure continuouscoverage by physicians licensed under IC 25-22.5 for inpatientemergencies.
As added by P.L.96-1994, SEC.1.
IC 16-21-2-15.4
Hospital procedures to aid in the identification of newborns andreduction of newborn and infant abductions; prerequisites tolicensure Sec. 15.4. (a) To obtain a license under this chapter, a hospitalmust demonstrate that the hospital has established proceduresdesigned to reduce the likelihood of abduction of newborn babiesand other infants from the hospital. These procedures may includethe following:
(1) Architectural plans to control access to areas of infant care.
(2) Video camera observation of areas of infant care.
(3) Procedures to identify hospital staff and visitors.
(b) To obtain a license under this chapter, a hospital mustdemonstrate that the hospital has established procedures to aid in theidentification of newborns and other infants. These procedures mayinclude the following:
(1) Footprinting of newborn infants by staff who have beentrained by law enforcement personnel.
(2) Photographing of newborn infants at the time of their birthand photographing of other infants upon their admission to thehospital.
(3) Maintaining full written descriptions of each infant togetherwith their footprints and photographs.
(4) Obtaining and retaining cord blood samples at the time of aninfant's birth for purposes of conducting genetic testing.
(c) Failure to comply with this section is grounds for suspensionor revocation of a hospital's license.
As added by P.L.12-1994, SEC.11.
IC 16-21-2-16
Third party billing notice
Sec. 16. A hospital, an ambulatory outpatient surgical center, anabortion clinic, or a birthing center that provides to a patient noticeconcerning a third party billing for a service provided to the patientshall ensure that the notice:
(1) conspicuously states that the notice is not a bill;
(2) does not include a tear-off portion; and
(3) is not accompanied by a return mailing envelope.
As added by P.L.178-2003, SEC.4. Amended by P.L.96-2005,SEC.11.