10.07.08.08

.08 Affiliated Hospitals.

A. The freestanding medical facility shall be reviewed under the affiliated hospital's accreditation by the Joint Commission on Accreditation of Healthcare Organizations.

B. The governing body of the affiliated hospital shall provide administrative and clinical oversight for the care and services provided by the freestanding medical facility. Services of the facility shall be reviewed and monitored consistent with the hospital's bylaws, including but not limited to:

(1) Patient safety;

(2) Peer review;

(3) Medical staff;

(4) Risk management; and

(5) Quality improvement.

C. The Department may issue a waiver for the requirement for accreditation if the affiliated hospital is not accredited or if the hospital is actively seeking accreditation.