UM 11, Elements A and C, factor 7 require organizations to have a process for monitoring that policies and procedures are followed for all other factors (factors 1–6) in this element at least annually. Policies and procedures must describe the monitoring process for factor 7.
For UM 11, Elements B and D, the organization submits evidence that it identified, analyzed and acted only on modifications to receipt and notification dates (UM 5) that did not meet the organization’s policies and procedures.
MBHO 2022