A freestanding medical facility shall be open to inspection at all times by the Department for annual licensure surveys, revisit surveys, and complaint investigations. Licensure Standards. When conducting a licensure or complaint survey, the Department shall use this chapter as well as the: Joint Commission on Accreditation of Healthcare Organization, 2006 Hospital Accreditation Standards; COMAR 10.07.06; COMAR 10.07.01.24, .26 and .33; and ACEP Policy Statement: Emergency Department Planning and Resources Guidelines. Responsibility of the Freestanding Medical Facility. The facility shall make the following documents available for review by the Department: Policies and procedures; Minutes of committee meetings; and Data and documentation related to oversight of the freestanding medical facility at the affiliated hospital.