Section 116.100  Quality Assurance

a)         A registered professional nurse, advanced practice nurse, licensed practical nurse, pharmacist or physician shall review the following for all individuals:

1)         medication orders;

2)         medication labels and medications listed on the medication administration record to ensure that they match physician orders; and

3)         medication administration records (for persons who are not self-medicating) to ensure that they are completed appropriately for:

A)        medication administered as prescribed;

B)        refusal by the individual; and

C)        full signatures provided for all initials used.

b)         Reviews shall occur at least quarterly, but may be done more frequently at the discretion of the registered professional nurse and/or advanced practice nurse.

c)         A quality assurance review of medication errors for the purpose of monitoring and recommending corrective action shall be conducted within seven days after occurrence and included in the annual review.

d)         Documentation of the review and the review date shall be retained for at least five years.

e)         All quality assurance records shall be confidential and may only be disclosed in accordance with the provisions of Part 21 of Article VIII of the Code of Civil Procedure [735 ILCS 5/8-2101 through 8-2105].

f)         Nothing in this Part shall limit or restrict the reporting of medication errors as possible abuse or neglect or the investigation by the Office of Inspector General of possible abuse or neglect in accordance with the Department's rules on Office of Inspector General Investigations of Alleged Abuse or Neglect and Deaths in State-Operated and Community Agency Facilities (59 Ill. Adm. Code 50).