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 chapter
applies to all hospitals, ambulatory outpatient surgical centers,
abortion clinics, and birthing centers.
(b) This chapter does not apply to a hospital operated by the
federal government.
(c) This chapter does not affect a statute pertaining to the
placement 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 outpatient
surgical 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 under
IC 4-22-2 to do the following concerning birthing centers and
abortion 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, and
maintenance of medical records.
(4) Establish procedures for the issuance, renewal, denial, and
revocation of licenses under this chapter. The rules adopted
under 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 not
licensed under this chapter; or
(2) advertises the operation of a birthing center or an abortion
clinic 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 is
covered by this chapter. A decision of the council under this section
is 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 the
advice 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 supreme
authority in the hospital and is responsible for the following:
(1) The management, operation, and control of the hospital.
(2) The appointment, reappointment, and assignment of
privileges to members of the medical staff, with the advice and
recommendations of the medical staff, consistent with the
individual training, experience, and other qualifications of the
medical staff.
(3) Establishing requirements for appointments to and
continued service on the hospital's medical staff, consistent with
the appointee's individual training, experience, and other
qualifications, including the following requirements:
(A) Proof that a medical staff member has qualified as a
health care provider under IC 16-18-2-163(a).
(B) The performance of patient care and related duties in a
manner that is not disruptive to the delivery of quality
medical care in the hospital setting.
(C) Standards of quality medical care that recognize the
efficient and effective utilization of hospital resources,
developed by the medical staff.
(4) Upon recommendation of the medical staff, establishing
protocols within the requirements of this chapter and 410 IAC
15-1.2-1 for the admission, treatment, and care of patients with
extended 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 the
Indiana medical licensing board the results and circumstances of a
final, a substantive, and an adverse disciplinary action taken by the
governing board regarding a physician on the medical staff or an
applicant for the medical staff if the action results in voluntary or
involuntary resignation, termination, nonappointment, revocation, or
significant reduction of clinical privileges or staff membership. The
report shall not be made for nondisciplinary resignations or for minor
disciplinary action.
(b) The governing board and the governing board's employees,
agents, consultants, and attorneys have absolute immunity from civil
liability for communications, discussions, actions taken, and reports
made concerning disciplinary action or investigation taken or
contemplated if the reports or actions are made in good faith and
without 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 the
governing 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 the
purpose of reducing morbidity and mortality and for the
improvement of the care of patients in the hospital, including
the following:
(A) The quality and necessity of care provided.
(B) The preventability of complications and deaths occurring
in 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 conduct
a retrospective medical review have absolute immunity from civil
liability for the following:
(1) Communications made in committee meetings.
(2) Reports and recommendations made by the committee
arising from deliberations by the committee to the governing
board of the hospital or another duly authorized medical staff
committee.
As added by P.L.2-1993, SEC.4.
IC 16-21-2-9
Practice of medicine not authorized by chapter; performance of
health 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 to
engage in the practice of medicine. However, this chapter does not
prohibit the performance of health care services by a hospital
employee in a hospital when that performance is delegated or
ordered 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 under
IC 4-21.5-3-5 before establishing, conducting, operating, or
maintaining a hospital, an ambulatory outpatient surgical center, an
abortion 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 license
on 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 standards
for a hospital, an ambulatory outpatient surgical center, an
abortion clinic, or a birthing center, and with rules adopted
under this chapter; and
(3) the applicant has complied with section 15.4 of this chapter.
(b) The application must contain the following additional
information:
(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 services
to be provided under the general hospital license, including any
service that would otherwise require licensure by the state
department 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 of
a building or structure that, when completed, will be subject to
licensure as a hospital or an ambulatory outpatient surgical center
under this article. The term does not include the acquisition or
installation of medical equipment or the purchase of the services of
an architect, engineer, or consultant to prepare plans or studies
related to a construction project.
(b) Except as provided in subsection (c), this section applies to a
hospital or an ambulatory outpatient surgical center for which
licensure is required under this article.
(c) This section does not apply to:
(1) a hospital or an ambulatory outpatient surgical center that is
operated by the federal government or an agency of the federal
government; or
(2) a construction project begun before July 1, 2005.
For purposes of this subsection, a construction project is considered
to have begun on the day that the physical erection, installation,
alteration, repair, or remodeling of the building or structure
commences.
(d) Before the owner of:
(1) a hospital or proposed hospital may begin a construction
project that is estimated by the owner to cost at least ten million
dollars ($10,000,000); or
(2) an ambulatory outpatient surgical center or a proposed
ambulatory outpatient surgical center may begin a construction
project that is estimated by the owner to cost at least three
million dollars ($3,000,000);
the owner shall hold at least two (2) public hearings concerning the
construction 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 the
standards 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 from
the site of the construction project;
(B) be held exclusively by the owner or the owner's
representative; and
(C) include an announcement from the owner or the owner's
representative 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 health
care services that will be provided by the hospital or
ambulatory outpatient surgical center as a result of the
construction 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 cause
any information or materials possessed or held by the owner or the
owner's employee, contractor, agent, or representative to be
discoverable 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 hearing
held under this section may not cause a delay in or denial of the
issuance of a license under this article.
(i) Compliance with this section may be enforced only by the state
department.
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 fee
at 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 further
evidence; or
(2) request additional information concerning the application
and conduct an investigation to determine whether a license
should 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 outpatient
surgical 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 renewal
fee 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 100
beds
Sec. 15. A hospital with at least one hundred (100) beds shall
have on duty at all times at least one (1) physician licensed under
IC 25-22.5. Implementation of this section shall be subject to rules
promulgated by the state department of health to ensure continuous
coverage by physicians licensed under IC 25-22.5 for inpatient
emergencies.
As added by P.L.96-1994, SEC.1.
IC 16-21-2-15.4
Hospital procedures to aid in the identification of newborns and
reduction of newborn and infant abductions; prerequisites to
licensure
Sec. 15.4. (a) To obtain a license under this chapter, a hospital
must demonstrate that the hospital has established procedures
designed to reduce the likelihood of abduction of newborn babies
and other infants from the hospital. These procedures may include
the 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 must
demonstrate that the hospital has established procedures to aid in the
identification of newborns and other infants. These procedures may
include the following:
(1) Footprinting of newborn infants by staff who have been
trained by law enforcement personnel.
(2) Photographing of newborn infants at the time of their birth
and photographing of other infants upon their admission to the
hospital.
(3) Maintaining full written descriptions of each infant together
with their footprints and photographs.
(4) Obtaining and retaining cord blood samples at the time of an
infant's birth for purposes of conducting genetic testing.
(c) Failure to comply with this section is grounds for suspension
or 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, an
abortion clinic, or a birthing center that provides to a patient notice
concerning a third party billing for a service provided to the patient
shall 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.