Each pharmacy and facility shall establish and maintain a quality assurance and performance program that monitors performance of the ADDD, which is evidenced by written policies and procedures that are made readily available on request to the commission or its designee. Electronic documents made available on a computer at the facility or pharmacy are permissible. The responsible manager shall perform annual audits of compliance with all ADDD policies and procedures. The quality assurance program shall include, but is not limited to:

(1) Method for ensuring accurate replenishment of the ADDD;

(2) Procedures for conducting quality control checks of drug removal for accuracy;

(3) Method for reviewing override data and medication error data associated with ADDD and identifying opportunities for improvement.