FAQ Directory: Managed Behavioral Healthcare Organization Accreditation

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5.15.2022 MBHO: Delegation Oversight System Controls Monitoring - Audits Are both the organization and delegate required to conduct system controls audits for factor 5 in UM 12, Element C and CR 8, Element C?

Both the organization and delegate must monitor the delegate’s system security controls as part of the delegation oversight requirements and may choose audit as the monitoring method. If auditing is the chosen method, the delegate provides an audit report of modifications that did not comply with its policies and procedures or with the delegation agreement.

The organization is not required to conduct an audit if it determines that the delegate adequately monitored and reported noncompliant modifications, but must provide documentation (a report, meeting minutes or other evidence) that it reviewed and agreed with the delegate’s findings. If the organization determines that the delegate did not adequately monitor noncompliant modifications, it must conduct its own audit of the delegate’s system controls.

The organization must submit its documentation and the delegate’s documentation as part of the survey.
 

MBHO 2022