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(ii) Except as specified in paragraph (i)(4)(iii) of this section, if no end date is indicated on the ACO's application or otherwise provided to CMS in a form and manner specified by CMS, described in paragraph (i)(4)(i) of this section, CMS applies a 90-day duration for purposes of determining the time period during which the ACO was ( affected by the extreme and uncontrollable circumstance

M.PritchardC.KrimpenfortP.BernsA.et al (2014)

But this usually only happens after someone complains, one practitioner at a time

Maintains Sterility Each vial puncture introduces a small contamination risk from the needle or the environment