Blog | The FDA Group

How to Comply with Stage 1 of FDA's LDT Final Rule: A Complete Guide

Written by The FDA Group | November 4, 2024

The FDA's Final Rule on Laboratory Developed Tests (LDTs), published on May 6, 2024, represents the most significant regulatory change in the laboratory testing industry in decades. This shift from enforcement discretion to active regulation reflects the FDA's growing concerns about the complexity and widespread use of modern LDTs. 

As a consulting partner offering a deep bench of laboratory and medical device professionals with extensive experience in both clinical and regulatory environments, we recognize the magnitude of this transition and its impact on laboratory operations. 

This guide provides a detailed roadmap for achieving Stage 1 compliance by the May 6, 2025 deadline.

We also recommend watching the following webinar hosted by ARUP's Chief Medical Officer and Senior Director of Governmental Affairs, Jonathan Genzen, MD, PhD, and Chief Compliance Officer, Jonathan Carr, JD. It provides an excellent overview of the requirements included in the final rule and how these requirements differ across certain settings and types of testing.

A Brief Background

LDTs have historically occupied a unique position in the diagnostic landscape. Under the FDA's previous approach of enforcement discretion, these tests provided crucial diagnostic capabilities, particularly in areas where commercial products were unavailable. This discretionary approach stemmed from the traditional nature of LDTs as relatively simple tests performed on a small scale within single laboratories.

However, the landscape has evolved dramatically. Modern LDTs often represent sophisticated, high-volume testing operations that significantly impact patient care decisions. This evolution and growing concerns about test validation and performance have driven the FDA's decision to implement comprehensive oversight.

The Final Rule amends 21 CFR Part 809.3(a) to explicitly include LDTs in the definition of in vitro diagnostic products. This amendment clarifies that IVDs encompass all products intended for use in the collection, preparation, and examination of specimens from the human body, regardless of whether a traditional manufacturer or a laboratory produces them. 

The FDA’s Phased Implementation Timeline

Recognizing the significant impact this regulatory change will have on laboratories, the FDA has established a phased implementation timeline.

This approach allows laboratories to adapt to the new requirements gradually over four years. (The FDA often officially refers to implementing these regulations as the phase-out of enforcement discretion. In other words, the “phase-out” of enforcement is a “phase-in” of regulatory requirements.)

Here's a quick look at the key dates and requirements:

Stage 1 (May 6, 2025)

By this date, laboratories must implement:

  • Medical Device Reporting (MDR) requirements (21 CFR Part 803)
  • Correction and removal reporting requirements (21 CFR Part 806)
  • Complaint file Quality System (QS) requirements (21 CFR Part 820.198)

Stage 2 (May 6, 2026)

By this date, laboratories must implement:

  • Registration and listing requirements (21 CFR Parts 607 and 807, Subparts A-D)
  • Labeling requirements ​​(21 CFR Parts 801 and 809)
  • Investigational use requirements (21 CFR Part 812)

Stage 3 (May 6, 2027)

By this date, laboratories must implement Quality System Requirements as outlined in 21 CFR Part 820.

A few key considerations here:

  • Not all requirements of 21 CFR Part 820 will apply to LDTs.
  • Focus areas include Design Controls, Purchasing Controls, Acceptance Activities, CAPA, and Records Requirements.
  • The FDA's incorporation of ISO 13485 within 21 CFR 820 (QMSR) is expected to occur before this deadline. Laboratories should work towards ISO 13485 requirements in preparation.

Stage 4 (November 6, 2027)

By this date, laboratories must submit premarket approval (PMA) applications for high-risk LDTs.

Stage 5 (May 6, 2028)

Laboratories must submit premarket notifications (510(k)) or De Novo classification requests for moderate and low-risk LDTs.

Throughout this phased implementation, laboratories should continuously assess their LDT portfolio, prioritize resources, and develop a strategic plan to meet each deadline. It's crucial to start preparations early, particularly for high-risk LDTs requiring more extensive data and earlier submission deadlines.

Partial Exemptions and Targeted Enforcement Discretion

The FDA's Final Rule includes specific exemptions (carve-outs) for certain LDTs. These tests will face reduced regulatory oversight, including previously existing tests ("grandfathered" LDTs), as long as they haven't undergone significant modifications to their use, operation, technology, or safety specifications.

The exemptions also cover "1976-Type LDTs" — manual tests performed by specialists using legally approved components in CLIA-certified labs. Additionally, certain Human Leukocyte Antigen (HLA) tests used in transplant procedures are exempt when performed in qualified laboratories.

Several other categories receive this reduced oversight: forensic tests, military and VA tests, and tests approved by New York State's Clinical Laboratory Program. Healthcare systems can also develop tests for unmet patient needs when no FDA-approved alternative exists or isn't suitable. Finally, non-molecular blood typing tests for rare antigens are exempt when no alternatives are available, though this doesn't apply to molecular testing methods.

Below is a chart showing which tests are included and excluded in the phase-out. 

Click on the table or here to open it larger in a new window.

Tests excluded from the final rule

Notably, certain test types remain unaffected by the FDA's shift away from enforcement discretion. Essentially, the FDA anticipates that the following categories of devices will continue to adhere to the full medical device regulatory framework:

  • Blood Donor Screening tests designed for screening blood donors or human cells, tissues, and cellular and tissue-based products (HCT/P) for infectious diseases.
  • Tests intended for emergencies declared under §564 of the FD&C Act. In conjunction with the Final Rule, the FDA released a draft guidance on considerations for adopting enforcement discretion policies for unauthorized tests during future public health emergencies. Additionally, the FDA issued a second draft guidance on enforcement policy for specific tests intended for immediate public health response without a declaration under the emergency use authorization provisions at §564 of the FD&C Act. The Final Rule highlighted the significant issues caused by ineffective tests during the COVID-19 pandemic as a primary reason for maintaining regulatory oversight of these tests.
  • Direct-to-consumer tests. As noted in the preamble to the LDT final rule, the FDA's general enforcement discretion has not been applied to tests intended for consumer use without "meaningful involvement by a licensed healthcare professional," due to the higher risks these tests pose to patients.
  • LDTs included in the FDA's ongoing voluntary pilot program for certain oncology drug products.

The Stage 1 Compliance Challenge

For clinical laboratories, the transition from traditional quality systems to FDA-compliant reporting systems represents a significant operational challenge. While CLIA-certified laboratories already maintain robust quality programs, the MDR requirements demand a more structured approach to event reporting and investigation. Success requires understanding how these three core systems work together and building them with both compliance and practicality in mind.

The three required systems serve distinct but interconnected functions in ensuring test quality and patient safety:

  • Medical Device Reporting focuses specifically on events that may have caused or contributed to death, serious injury, or significant malfunction, with mandatory 30-day reporting timelines.
  • The correction and removal reporting system manages product modifications and withdrawals, requiring 10-day reporting for serious issues classified as Class 1 or 2 recalls.
  • The complaint handling system serves as the foundation, capturing and documenting all quality-related communications while feeding relevant information to the other two systems.

Integration of all three systems is therefore crucial to successful implementation. These systems must work together seamlessly while maintaining their distinct regulatory requirements. Clear triggers must exist for escalating complaints to MDR evaluation or correction/removal assessment, supported by consistent documentation practices across all three systems.

It’s also important to acknowledge the resourcing challenges here. Clinical laboratories, while well-versed in CLIA compliance and quality management, face a fundamentally different challenge with FDA requirements that, in most cases not only justifies, but demands specialized consulting support. While CLIA focuses primarily on quality control and proficiency testing, FDA's systems require sophisticated risk assessment, complex decision-making frameworks, and specific documentation practices that more closely resemble medical device manufacturing than traditional laboratory operations. 

  • MDR systems require a nuanced understanding of what constitutes reportable events, with decision trees that can mean the difference between appropriate reporting and either over-reporting (creating unnecessary burden) or under-reporting (creating compliance risk).
  • Corrections and removal decisions involve a careful assessment of health hazard evaluations and recall classifications that most laboratories have never encountered.
  • Even complaint handling under FDA oversight differs significantly from typical laboratory incident management, requiring specific documentation elements and trending analyses that align with the FDA's enforcement approach rather than CLIA's quality improvement focus. 

Experienced consultants bring not only knowledge of these requirements but also practical implementation strategies tested across multiple organizations, helping laboratories avoid common pitfalls while building sustainable systems that satisfy FDA expectations without overwhelming laboratory resources.

Contact us if the work projects we explain in the subsequent sections of this guide make it clear that your team requires expert third-party consulting support. We have the bench of contracted talent to help laboratories plan and execute all components of Stage 1 compliance.

Medical Device Reporting (MDR) — (21 C.F.R. Part 803)

At Stage 1, the FDA aims to systematically monitor significant adverse events to identify "problematic" LDTs in the market. Starting May 6, 2025, laboratories must comply with MDR requirements, which mandate reporting certain events to the FDA. 

  • A reportable event occurs when an LDT reasonably suggests it has or may have caused or contributed to a death or serious injury, or has malfunctioned in a way that would likely cause or contribute to a death or serious injury if the malfunction were to recur.
  • A "serious injury" is defined as a condition that is life-threatening, results in permanent impairment or damage to body function/structure, or requires medical/surgical intervention to prevent permanent impairment.
  • A "malfunction" means the failure of a device to meet its performance specifications or otherwise perform as intended.

Importantly, laboratories must report events even if they can only determine the LDT may have caused or contributed to a death or serious injury. Reportable events can include user errors, issues with materials or components, design issues, labeling issues, issues resulting from off-label use, or other malfunctions. Reporting an event does not constitute an admission that the LDT caused or contributed to the harm.

Here at the reporting timeframes at a glance:

  • Standard reporting: Within 30 calendar days after becoming aware of a reportable event.
  • Emergency reporting: Within 5 working days if remedial action is needed to prevent unreasonable risk or substantial harm to public health, or if FDA specifically requests a report.
  • For recurring events, laboratories can request to submit quarterly summary reports instead of individual reports (for example, reporting failed runs caught by control failures).

 The steps to compliance

1. Develop formal procedures for identifying and evaluating adverse events related to your LDTs.

Laboratories must establish detailed protocols that outline exactly how staff should recognize and escalate potential issues, creating specific criteria for what constitutes a reportable event. This includes developing clear definitions of what constitutes "serious injury" and "malfunction" in the context of their specific LDTs — training staff on recognizing these situations and creating explicit documentation requirements. 

Laboratories will need procedures including step-by-step workflows for gathering initial information, establishing clear chains of command for internal reporting, and implementing systematic investigation methods. These procedures must address how to handle both clear-cut cases and situations where causation is less certain, remembering that events must be reported even when the LDT may have only contributed to an adverse outcome.

2. Create a standardized review process for determining reporting requirements and timelines.

This involves developing evaluation frameworks that guide staff through consistent assessment of potential reportable events. The process should include detailed decision trees that help staff determine whether an event meets reporting thresholds and identify which reporting timeline applies (30 days for standard reports, 5 days for emergency situations, or potential qualification for quarterly summary reporting for recurring events). 

  • Laboratories need to establish clear criteria for distinguishing between standard and emergency reporting situations, define what constitutes "remedial action" requiring expedited reporting, and include quality control checkpoints to verify proper categorization.
  • Laboratories should also develop specific protocols for handling recurring events that might qualify for quarterly summary reporting, including criteria for determining when this approach is appropriate.

3. Implement systems for timely submission of initial and supplemental reports to the FDA through the Electronic Submissions Gateway (ESG) using Form 3500A.

This requires careful attention to both technical and procedural aspects. Laboratories must establish and maintain proper accounts and credentials for FDA's ESG, making sure multiple staff members are trained and authorized to submit reports to prevent delays due to staff absence. 

The system should include detailed procedures for completing Form 3500A accurately, including guidance for handling different types of events and ensuring all required fields are properly completed.

  • Laboratories should also develop validation procedures to verify report accuracy before submission and create tracking systems to monitor reporting deadlines and submission status.
  • The system should include processes for preparing and submitting supplemental reports when new information becomes available about previously reported events.

4. Maintain comprehensive documentation of all complaints.

Maintaining comprehensive documentation requires developing systems that ensure all relevant information is captured and readily accessible. This includes creating standardized forms or templates for documenting different types of events, establishing clear filing systems that facilitate both storage and retrieval of records, and implementing quality control measures to ensure documentation completeness. 

The documentation system should support trend analysis capabilities to help identify patterns or systematic issues that might require broader corrective actions. Record-keeping systems should track not only the initial event and investigation but also any follow-up actions, supplemental reports, and ongoing monitoring of corrective measures.

All documentation should be maintained to facilitate delivery during FDA inspection and verification, with clear organization systems that allow quick access to specific records when needed.

Correction and Removal Requirements — (21 C.F.R. Part 806)

The FDA is requiring laboratories offering nonexempt LDTs to comply with correction and removal requirements as part of its broader effort to systematically monitor and identify "problematic" LDTs in the market. These requirements require that laboratories promptly report certain corrective actions and maintain comprehensive records of all corrections and removals, even those that don't require reporting.

A laboratory must submit a written report to the FDA when correcting or removing an LDT for two specific reasons:

  1. to reduce a health risk posed by the LDT, or
  2. to remedy any unlawful activity resulting from the LDT's use, such as improper labeling.

The FDA defines a correction as any repair, modification, adjustment, relabeling, destruction, or inspection (including patient monitoring) performed without moving the device from its point of use. A removal involves physically relocating the device to another location for any of these same actions.

Not all corrections or removals trigger reporting requirements. Actions taken solely to improve performance, quality, or profitability don't require reporting unless they address health risks or legal compliance issues. Furthermore, if an event has already been reported under MDR requirements, no additional report is needed.

However, when a correction or removal is undertaken to address health risks or legal compliance, laboratories must submit their report within 10 working days of initiating the action. Reports can be submitted via email to the FDA or through the ESG using eSubmitter.

Here are examples of when corrections or removals are required:

  • When lab personnel errors result in incorrect test results being reported.
  • When contaminated reagents affect multiple reported test results.
  • When systematic issues require correction of previously reported results.

Here are examples of when corrections or removals are NOT required:

  • When specimen collection errors occur at unaffiliated collection sites.
  • When issues are caught before test results are reported.
  • When errors stem from external systems not part of the LDT.

The steps to compliance

1. Establish comprehensive documentation systems.

Laboratories must maintain records of all corrections and removals, whether reportable or not. Laboratories must develop standardized documentation procedures that ensure consistent recording of all necessary information, including detailed narrative descriptions of events, complete chronological timelines of actions taken, and thorough justifications for all decisions made.

The system should include specific templates or forms for different types of corrections and removals, ensuring all required FDA information is captured even for non-reportable events.

  • Documentation must include clear identification of the LDT involved, a detailed description of the issue necessitating correction or removal, assessment of health risks or legal compliance concerns, and copies of all related communications.
  • Laboratories should implement quality control measures to verify documentation completeness and accuracy, considering FDA's authority to access and review these records at any time. The system should also support trend analysis capabilities to help identify patterns that might indicate broader systemic issues requiring attention.

2. Implement clear decision processes.

Create systematic approaches for evaluating whether corrections or removals require FDA reporting. This includes creating detailed decision trees or evaluation frameworks that guide staff through consistent assessment of health risks and legal compliance implications. The process should include specific criteria for determining when actions are taken solely for quality improvement or business reasons versus when they address health risks or legal compliance issues.

Clear protocols should be established for documenting the rationale behind all decisions, particularly when determining that reporting is not required. The process should include quality control checkpoints to verify proper categorization of actions and ensure consistent application of decision criteria.

Laboratories should also develop specific procedures for handling situations where multiple correction or removal actions might be related, ensuring proper evaluation of aggregate impacts and reporting requirements.

3. Develop efficient reporting systems.

Set up streamlined processes for submitting required reports within the 10-working-day deadline. Laboratories must create specific procedures for preparing and submitting reports, including detailed instructions for using FDA's electronic submission systems or email reporting processes.

The system should include clear workflows for gathering required information, validating report contents, obtaining necessary internal approvals, and tracking submission status. Procedures should address both initial reports and any necessary updates or supplemental information.

Training programs should ensure multiple staff members are capable of preparing and submitting reports to prevent delays due to personnel absence. The system should include mechanisms for tracking reporting deadlines and verifying successful submissions, with built-in reminders or alerts to prevent missed deadlines.

4. Maintain investigation records.

Keep detailed records of all investigation findings, corrective actions taken, and follow-up measures implemented. Records should include detailed documentation of initial issue identification, investigation methodologies, findings, risk assessments, and all corrective actions implemented.

The documentation should clearly define the scope of any issues identified, including potential impacts on patient results or healthcare decisions. Records must track all steps taken to address identified issues, including verification activities to confirm the effectiveness of corrective actions.

The system should include procedures for documenting follow-up measures and monitoring activities to ensure the long-term resolution of issues. Investigation records should be maintained to allow easy correlation with related complaint files, MDR reports, or other quality system documentation. The record-keeping system should support both internal quality management needs and potential FDA inspections, with clear organization systems that facilitate efficient review and verification of records.

Complaint Files — (21 C.F.R. Part 198)

At Stage 1, laboratories offering nonexempt LDTs must comply with the FDA's Quality System complaint file requirements, establishing formal procedures for handling complaints. A complaint is defined as any written, electronic, or oral communication alleging deficiencies in a device's identity, quality, durability, reliability, safety, effectiveness, or performance after it is released for distribution. For LDTs, this typically involves reports of erroneous test results.

The laboratory must establish a formally designated compliance unit staffed by appropriately trained individuals. While this unit may be located separately from the laboratory, all complaint-related information must remain readily accessible. The unit must implement written procedures ensuring uniform and timely processing of all complaints, including proper documentation of oral complaints upon receipt and evaluation of whether additional adverse event reporting is required.

The complaint handling system serves two critical purposes: enabling laboratories to identify trends requiring further investigation and allowing the FDA to assess complaint processes during inspections. FDA recommends maintaining all complaint files related to an LDT in a single location to facilitate trend analysis. This centralized approach helps identify patterns that might indicate systemic issues requiring broader corrective actions.

Here's what every complaint file must include:

  • Test identification
  • Date complaint received
  • Complainant's name, address, and phone number
  • Nature and details of the complaint
  • Investigation dates and results
  • Corrective actions taken
  • Any reply to the complainant

The steps to compliance

1. Establish formal complaint procedures.

Laboratories must create comprehensive written procedures covering every aspect of complaint handling, from initial receipt through final resolution. These procedures must detail specific protocols for receiving both written and oral complaints, with particular attention to ensuring oral complaints are immediately documented with the same level of detail as written ones.

Staff must be trained on recognizing what constitutes a complaint — any communication suggesting device deficiencies, regardless of the source or severity. The procedures should include clear evaluation criteria for assessing complaints, specific documentation requirements, and defined workflows for processing each type of complaint.

Even seemingly minor issues, such as complaints about turnaround time or specimen collection requirements, must be processed through this formal system. The procedures should also establish clear hierarchies for complaint handling and define responsibilities for different staff members throughout the complaint management process.

2. Document all complaints thoroughly.

Every complaint must be recorded in detail, regardless of its perceived severity or validity. The documentation system should capture all required elements: complete test identification, precise timing of the complaint receipt, comprehensive contact information for the complainant, and a detailed description of the reported issue.

For complaints that don't warrant investigation, the file must include a thorough written justification for this decision, along with a clear identification of the responsible decision-maker. For investigated complaints, documentation should include a complete chronological record of the investigation, including all findings, decisions made, and actions taken.

Documentation must also include copies of all communications with the complainant, including any responses sent. Even when complaints come through indirect channels, such as sales representatives hearing customer concerns, they must be documented with the same thoroughness as direct complaints.

3. Implement investigation procedures.

Laboratories need to develop detailed protocols for conducting investigations, beginning with initial assessment procedures that help determine the scope and severity of the reported issue. The investigation methodology should include clear steps for gathering and analyzing relevant data, reviewing related documentation, interviewing involved personnel when necessary, and examining any affected specimens or test results.

Documentation requirements for investigations should specify what information must be recorded at each step, including timestamps for all activities. Clear decision-making criteria must be established for determining when corrective actions are needed and what type of actions are appropriate.

The procedures should also include specific protocols for communicating with complainants throughout the investigation process, including templates for standard communications and guidelines for handling different types of inquiries.

4. Create quality control measures.

Laboratories must establish comprehensive monitoring systems that track multiple aspects of complaint handling, including processing times, investigation thoroughness, and consistency of documentation. These systems should include regular audits of complaint files to verify proper documentation and appropriate handling of all complaints.

Timeline tracking mechanisms should be implemented to ensure complaints are processed efficiently and all required deadlines are met. Trend analysis capabilities must be built into the system to identify complaint patterns that might indicate systemic issues requiring broader corrective actions.

Regular reviews should be conducted to verify that corrective actions have been properly implemented and are effectively addressing identified issues. All records must be maintained to ensure easy accessibility for FDA inspections, with clear organization systems that facilitate both internal reviews and external audits. Quality control measures should also include regular staff training and competency assessments to ensure consistent implementation of all complaint-handling procedures.

 Examples of How These Systems Work in Practice

Consider the following real-world scenarios that laboratories may encounter.

Laboratory Processing Errors

If laboratory personnel inadvertently swap specimens during testing, resulting in Patient A receiving Patient B's results and vice versa, the incident triggers multiple regulatory obligations. This scenario requires recording as a complaint, thorough investigation, and potentially MDR reporting if the erroneous results may have caused or contributed to serious injury.

For instance, in cancer diagnosis testing, where incorrect results could lead to unnecessary treatment for one patient and delayed treatment for another, MDR reporting would be required. The laboratory must also implement corrections and issue recalls of the original test reports, replacing them with corrected results.

Pre-analytical Errors

Contrast the previous example with specimen collection errors occurring at an unaffiliated blood draw site. While the outcome may be similar — switched specimens leading to incorrect result reporting — the regulatory requirements differ.

The laboratory must still document the complaint and conduct an investigation, but correction/removal reporting to the FDA is not required because the LDT itself functioned properly. This distinction highlights the importance of determining whether the error originated from the test system or from external factors.

Information System Issues

Modern laboratories rely heavily on Laboratory Information Management Systems (LIMS), creating another category of potential errors. Consider a case where the test performs correctly, but a defect in the validated commercial LIMS causes incorrect result reporting.

This scenario requires complaint documentation and investigation. If the erroneous result could cause serious injury, such as in diagnostic testing that directs treatment decisions, MDR reporting would be necessary. However, since the commercial LIMS is not considered part of the LDT device, no correction/removal reporting or recall to the FDA is required. Here we see the need to clearly define the boundaries of the LDT device when determining regulatory obligations.

 

Cross-System Integration and Implementation

Integration requires the development of a master process flow diagram showing how information moves between the three systems. This should include specific trigger points where complaints require escalation to MDR evaluation or correction/removal assessment.

The laboratory should create a comprehensive compliance calendar tracking all reporting deadlines and review requirements. This calendar should account for the various timing requirements: 30 days for MDR reporting, 10 days for Class 1 and 2 recalls, and internal timelines for complaint investigation and resolution.

Implementation should follow a phased approach with specific milestones:

  1. Complaint system development and deployment
  2. MDR system implementation and integration
  3. Correction and removal system development
  4. Full system integration and testing
  5. Staff training and practice runs

Each phase should include specific deliverables, success criteria, and validation requirements before moving to the next phase. The laboratory should develop detailed test scenarios covering various potential situations, from simple complaints to complex events requiring multiple system interactions.

Training programs must include role-specific modules with competency assessments for each staff level involved in the systems. These should incorporate hands-on practice using the actual forms and procedures staff will use in their daily work.

Quality monitoring should include specific metrics for system performance: complaint resolution times, MDR reporting compliance, investigation thoroughness, and documentation completeness. Regular audits should evaluate both individual cases and overall system performance against these metrics.

Additional Considerations

Below are several additional critical considerations that LDT firms should understand when implementing these systems.

Practical Implementation

Documentation requirements deserve special attention beyond basic system design. Laboratories must establish specific procedures for maintaining the integrity and retrievability of all records. This includes implementing version control for all procedures and forms, establishing audit trails for any record modifications, and ensuring all documentation is readily accessible for FDA inspection.

  • Given the interrelated nature of these systems, cross-referencing between complaint files, MDR reports, and correction/removal actions becomes crucial. Keep in mind that each system requires a robust change control process.
  • When modifications are made to test processes, complaint-handling procedures, or reporting mechanisms, laboratories must assess the impact on all three systems. For instance, a change in test methodology might require updates to complaint evaluation criteria, MDR reporting thresholds, and correction/removal classification procedures.

Electronic Systems and Data Management

Labs need to have electronic systems to manage the documentation and reporting requirements that stretch across all three of these systems. Laboratories should consider whether their existing LIMS or quality management software can be adapted to handle these new requirements or if additional systems are needed.

  • Any electronic systems used for these purposes must meet FDA's electronic records requirements. Custom worksheets and forms should be developed for each type of investigation and assessment. These should include specific fields for all required information and built-in logic to help guide decision-making. For example, MDR assessment forms should walk investigators through the criteria for reportability in a systematic, repeatable way.

Contractor and Vendor Management

Laboratories must establish clear procedures for handling complaints and events involving contracted services or purchased components. Errors occurring at contracted collection sites require different handling than internal errors. Clear procedures must specify how these situations are documented and when they trigger reporting requirements.

Business Continuity Considerations

Backup procedures must be established for all critical functions. This includes designating alternate personnel for key roles, establishing backup documentation systems in case of IT failures, and ensuring reporting capabilities are maintained even during system outages or other disruptions.

Quality Metrics and Performance Monitoring

Beyond basic compliance, laboratories should establish KPIs for each system:

  • Complaint investigation completion times
  • MDR reporting timeliness
  • Correction/removal action implementation efficiency
  • Documentation accuracy and completeness
  • Staff training completion rates
  • System integration effectiveness

Regular system reviews should examine these metrics to identify trends and improvement opportunities. This data can also help justify resource needs and system modifications over time.

Staff Roles and Responsibilities

Clear delineation of responsibilities is crucial. Laboratories should establish specific role definitions:

  • Who can receive and document complaints
  • Who is authorized to initiate MDR assessments
  • Who can classify corrections and removals
  • Who has authority to submit FDA reports
  • Who conducts investigations at each level
  • Who provides final approval for completed investigations and reports

Regular system reviews should examine these metrics to identify trends and improvement opportunities. This data can also help justify resource needs and system modifications over time.

Communication

Clear communication channels must be established for each system, including:

  • Internal notification pathways for potential events
  • Communication procedures for affected clients and healthcare providers
  • Protocols for interacting with the FDA
  • Methods for disseminating information about corrections and removals
  • Procedures for updating relevant staff about system changes and lessons learned

Regular system reviews should examine these metrics to identify trends and improvement opportunities. This data can also help justify resource needs and system modifications over time.

Compliance Project Orchestration and Resourcing

The scope of Stage 1 compliance encompasses three interconnected systems that must work seamlessly together while maintaining distinct regulatory requirements. This demands not only technical expertise in regulatory compliance but also a deep understanding of laboratory operations and existing quality systems. 

The path to compliance begins with establishing the foundational quality system elements that support all three required systems — MDR, corrections and removals, and complaint handling. Laboratories should map out dependencies between different implementation activities, identifying which elements must be completed before others can begin. For example, the complaint handling system must be operational before MDR procedures can be fully implemented, as complaints often trigger MDR evaluations. This critical path analysis helps laboratories avoid bottlenecks and ensure efficient resource utilization.

Working backward from the May 6, 2025 compliance deadline, laboratories should establish clear milestones that allow adequate time for system refinement and staff training. 

Key milestones typically include:

  • Completion of gap analysis
  • Development of core systems and procedures
  • Staff training
  • System validation

Each milestone should include specific success criteria and deliverables. Importantly, laboratories should build in buffer time between major milestones to accommodate unexpected challenges and allow for system optimization based on early implementation experience.

Most laboratories will find their current staff lack specific experience with FDA reporting requirements, while external consultants may need time to understand laboratory-specific workflows and constraints. Therefore, a successful implementation requires thoughtful resource allocation and clear delineation of roles between internal staff and external partners.

Resource allocation must align with the intensity of different implementation phases. The initial documentation development phase typically requires the heaviest investment in consulting support and internal staff time. As implementation progresses, resource needs shift toward training and system validation activities. Laboratories should plan for these changing resource requirements, ensuring adequate staffing and expertise are available at each phase. This includes identifying when specific subject matter experts need to be engaged and planning for potential resource constraints during high-intensity periods.

Perhaps the most challenging aspect of timeline management is balancing compliance implementation with ongoing laboratory operations. Successful laboratories typically adopt a staged implementation approach, rolling out new systems in controlled phases to minimize operational disruption. This might involve piloting new procedures in specific departments before full implementation or implementing basic system elements before adding more complex components.

Project leaders should work closely with operational managers to identify critical operational periods and adjust implementation timelines accordingly. Additionally, laboratories should establish clear criteria for when implementation activities take precedence over routine operations and when they need to be temporarily scaled back to accommodate operational demands.

Below is a recommended step-by-step strategy for orchestrating a Stage 1 compliance project before the May, 2025 deadline.

Immediate Action: Secure Regulatory Consulting Support
(As soon as possible)

Before beginning compliance activities, assess and secure necessary regulatory expertise. Evaluate existing regulatory/quality expertise within your organization, identify gaps, and define your need for external consulting support. Most labs will need significant support to lead and execute this compliance project. If you haven’t already secured your consulting resources, contact us as soon as possible to ensure you have the consultants you need to ensure compliance before the deadline.

You will need to work with a firm specializing in:

  • FDA medical device regulations
  • Laboratory quality systems
  • MDR reporting systems
  • Complaint handling procedures

Your consultant or support team should be qualified in the following areas:

  • Clinical laboratory operations
  • Gap assessments
  • System and procedure development
  • Training if necessary
  • Audit preparation
  • FDA compliance programs
  • Medical device reporting
  • Quality system implementation

Phase 1: Initial Assessment and Organization
(September to December 2024)

After securing your external support, your most crucial priority is engaging with your corporate compliance team to determine:

  • Whether the lab or health system compliance office will manage FDA compliance
  • Who will be ultimately responsible for each component
  • How the organizational structure will support compliance activities
  • How reporting structures will work within your organization

This conversation is essential because, unlike CLIA, where responsibilities clearly fall to the laboratory director, FDA compliance operates on an establishment basis tied to physical addresses. These early discussions will shape all subsequent compliance activities and procedural development.

In addition to this, your team should begin educating itself on the relevant FDA requirements for Stage 1. Your journey begins with mastering the Code of Federal Regulations as they relate to LDTs. This isn't a simple reading exercise; you'll need to dive deep into three key areas: Medical Device Reporting, corrections and removals, and complaint files. Keep in mind that a consultant can assist with compiling trainings in these areas.

Here are the steps we suggest teams take to self-educate on these requirements:

  1. Study the relevant Code of Federal Regulations sections for: Medical Device Reporting, Corrections and Removals, and Complaint Files.
  2. Watch the FDA's Stage 1 webinar multiple times to ensure thorough understanding.
  3. Review the MAUDE database to understand MDR reporting in practice. We suggest starting here.
  4. Study the medical device recall database to understand corrections/removals documentation. We suggest starting here.
  5. Familiarize yourself with MedWatch Form 3500A requirements.

Phase 2: Development of Procedures
(January to March 2025)

After establishing organizational responsibilities, focus on creating the required written procedures and systems. Each procedure should be detailed, practical, and aligned with both FDA requirements and your organization's structure. Ensure all relevant staff understand new procedures through a training program.

Below are the procedures and related details that must be established.

Medical Device Reporting Procedures:

  • Establish processes for identifying reportable events
  • Create clear criteria for distinguishing between 5-day and 30-day reporting requirements
  • Develop workflows for collecting required information
  • Define roles and responsibilities for reporting
  • Include procedures for completing Form 3500A

Corrections and Removals Procedures:

  • Define what constitutes a correction versus a removal
  • Establish documentation requirements
  • Create processes for determining when FDA reporting is required
  • Include procedures for maintaining records of all corrections/removals

Complaint Handling System:

  • Designate a formal unit responsible for complaints
  • Create procedures for:
  • Receiving complaints (both written and oral)
  • Processing complaints uniformly
  • Evaluating complaints for potential MDR reporting
  • Investigating complaints
  • Documenting investigation results
  • Maintaining records
  • Responding to complainants

Required Documentation Elements for Complaints:

  • Device name and identifiers
  • Complaint receipt date
  • Complainant contact information
  • Nature and details of complaint
  • Investigation dates and results
  • Corrective actions taken
  • Responses provided

Phase 3: Testing and Implementation
(March to April 2025)

Before the compliance deadline, test your procedures and establish necessary registrations.

For initial MDR reporting, use these FDA-established generic codes:

  • SCH: New York CLEP-approved LDTs
  • SCI: IVDs offered as LDTs but not true LDTs
  • SCJ: LDTs not under other enforcement discretion policies
  • SCK: Non-molecular antisera LDTs
Other steps here include testing all procedures with simulated events, obtaining an FDA Establishment Identifier (FEI) number, and enrolling in the FDA's electronic submission gateway. Choose between eSubmitter (low volume) or HL7 (high volume), and be sure to allow time for the verification process. Include approximately $10,000 in your 2025 budget for FDA registration fees.
 

Consultant Skillset Requirements for Stage 1 LDT Compliance

The transition to FDA oversight requires consultants with specific expertise in three core areas: regulatory knowledge, quality systems implementation, and laboratory operations. The primary consultant should bring deep experience with the FDA's medical device reporting requirements and practical knowledge of implementing these systems in real-world settings.

Regulatory expertise must cover MDR requirements (21 CFR Part 803), corrections and removals (Part 806), and complaint handling (Part 820.198). The consultant needs hands-on experience with FDA's Electronic Submissions Gateway, Form 3500A submissions, and understanding of how these requirements interact with existing CLIA regulations. They should also have experience guiding organizations through FDA inspections and regulatory correspondence.

Quality system development expertise is crucial for creating robust but practical documentation systems. This includes designing standard operating procedures, work instructions, forms, and tracking systems that satisfy FDA requirements while remaining usable in daily laboratory operations. The consultant must understand how to integrate new processes with existing laboratory workflows and develop effective training programs.

Given the scope of Stage 1 requirements, laboratories are engaging multiple consultants with complementary skills. 

A typical consulting team might include:

  • A lead regulatory consultant focusing on MDR systems and FDA requirements
  • A quality systems specialist handling documentation and process development
  • An IT consultant supporting electronic submission systems implementation
  • Laboratory operations specialists helping adapt systems to the LDT environment

The consulting team must excel at knowledge transfer, building internal capabilities that allow the laboratory to eventually operate these systems independently. Strong communication skills and experience managing similar implementations are essential, as consultants must work effectively with laboratory staff at all levels while navigating organizational change.

When selecting consultants, laboratories should prioritize demonstrated experience with similar implementations and understanding of both FDA requirements and laboratory operations. The right consulting team provides technical expertise and practical guidance for building sustainable compliance systems.

Getting Started: Your First Steps Toward Stage 1 Compliance

The path to Stage 1 compliance begins with three immediate actions that every laboratory should take upon finishing this guide. 

  1. First, conduct a preliminary inventory of your LDT menu, identifying which tests qualify as LDTs under the FDA's definition and whether any might fall under partial exemption categories. This inventory should include basic information about test volumes, complexity, and current quality control measures. This initial assessment provides the foundation for all subsequent planning and helps determine the scope of your compliance project.

  2. Second, evaluate your current quality management leadership and identify who will own the Stage 1 compliance project. This individual should be a senior laboratory director or quality manager with both the authority to drive organizational change and the bandwidth to oversee a major regulatory implementation. If no current staff member fits this profile, begin planning for additional hiring or leadership restructuring.

  3. Third, initiate preliminary discussions with potential consulting partners. Schedule exploratory conversations with a firm who can help you access the professionals you need to understand their approach to Stage 1 implementation, assess their relevant experience with both FDA requirements and laboratory operations, and begin developing a rough budget framework for the project. Contact us today to start the conversation.

A Few Common Pitfalls to Avoid

The transition to FDA oversight presents several common challenges that laboratories should anticipate and plan to address. 

The Documentation Trap

Early adopters of Stage 1 compliance have consistently identified underestimating the scope of documentation requirements as a primary challenge. Many laboratories initially approach MDR, corrections and removals, and complaint handling as simple extensions of their CLIA quality systems, failing to recognize the more rigorous documentation and investigation requirements of FDA oversight. To mitigate this risk, make sure you conduct thorough reviews of your current documentation practices against FDA requirements early in the implementation process, allowing adequate time to develop more comprehensive systems.

The Resource Squeeze

Resource allocation presents another significant challenge, particularly regarding staff time and engagement. Laboratories often underestimate the time required from key personnel during implementation, leading to competing priorities and delayed milestones. Quality managers and laboratory directors frequently find themselves stretched thin between routine operations and compliance activities, potentially compromising both. Successful implementations typically dedicate specific staff members to the compliance project, with clear backfilling plans for their routine responsibilities. Additionally, laboratories should establish explicit criteria for prioritizing compliance activities against their current operational demands.

The Practicality Balance

The most successful implementations maintain balance between thoroughness and practicality. While FDA compliance requires robust systems, these systems must remain workable within the laboratory's operational constraints. Laboratories should regularly assess whether new processes are being consistently followed and whether they're achieving their intended purposes. When procedures prove overly burdensome or ineffective, teams should be prepared to redesign them while maintaining regulatory compliance. This ongoing optimization process, guided by practical experience and consultant expertise, helps ensure the sustainability of Stage 1 compliance systems.

How The FDA Group Can Guide You to Compliance

As a leader in FDA regulatory consulting, The FDA Group offers comprehensive support for laboratories navigating the complexities of LDT regulation. Our experienced team brings deep expertise in both FDA compliance and laboratory operations, providing end-to-end guidance through every aspect of Stage 1 implementation and beyond.

We understand that most laboratories are encountering FDA oversight for the first time and have very limited resources and understanding of the road ahead. We've structured our services to ensure a smooth, efficient transition to compliance.

Our comprehensive compliance support services include, but are not limited to:

1. Initial assessment and strategic planning

  • Comprehensive gap analysis of current systems against FDA requirements
  • LDT portfolio review and exemption assessment
  • Development of detailed implementation roadmaps
  • Resource planning

2. System development

  • Design and implementation of MDR systems
  • Creation of corrections and removals procedures
  • Development of comprehensive complaint handling systems
  • Integration with existing CLIA quality systems
  • Documentation system development and optimization

3. Operational implementation

  • Staff training program development and delivery
  • Process validation and verification
  • Mock FDA inspections and audit preparation

4. Project management and resourcing

  • Implementation timeline development and management
  • Resoucing planning and consultant identification
  • Ongoing project management

The FDA Group offers flexible engagement models to meet your specific needs, from focused consulting on particular aspects of compliance to comprehensive program management. Our consultants can work on-site or remotely, scaling their involvement based on your internal capabilities and resource constraints.

Here are just a few of the reasons laboratories are partnering with us for compliance support:

  • Deep expertise in both FDA regulations and laboratory operations
  • Proven track record of successful regulatory implementations
  • Comprehensive understanding of the unique challenges facing clinical laboratories
  • Practical, efficiency-focused approach to compliance
  • Strong relationships with regulatory authorities
  • Ability to leverage best practices from across the industry

We believe in building true partnerships with our clients, working alongside your team to build sustainable compliance systems that enhance rather than hinder laboratory operations. Our consultants focus not just on meeting regulatory requirements but on optimizing processes to improve efficiency and quality while maintaining compliance.

Fill out and submit the form below to ensure you’re prepared by the Stage 1 deadline—on time and on budget.