CMS SOM App. A, Tag A-0507

number of doses must automatically be stopped after a reasonable time that is

predetermined by the medical staff.

Interpretive Guidelines §482.25(b)(5)

In accordance with accepted standards of practice, the medical staff, in coordination and

consultation with the pharmacy service, determines and establishes the reasonable time to

automatically stop orders for drugs and biologicals not specifically prescribed as to time or

number of doses. The hospital must implement, monitor, and enforce this automatic stop system.

It is important to note that hospitals with an electronic health record (EHR) system may have

time and dose parameters automatically built into computerized provider order entry (CPOE)

screens. These may be part of the hospital’s plan for addressing automatic stop orders.

Survey Procedures §482.25(b)(5)

• Review policies and procedures to determine that there is a protocol established by the

medical staff to discontinue and review patients’ medical records to determine

compliance with stop-order policy;

• Ask unit staff what happens in the case of drugs with no stop date or prescribed number

of doses. Are they aware of the automatic stop policy? Can they describe how it is

enforced?