This week’s “Ftag of the Week” on the CMSCG Blog is part of the Laboratory, Radiology and Other Diagnostic Services regulatory group, F773. This regulation outlines the requirements for the provision of lab services only when there is an appropriate order and when the lab must notify the ordering provider of results.
F773 states that:
- a nursing home must provide/obtain lab services only when ordered by a physician/ PA/ NP or clinical nurse specialist in accordance with State laws.
- The lab results must be promptly provided to the ordering practitioner if the results are outside clinical reference ranges indicating that the practitioner should be notified.
The first requirement – to do labs only when there is an appropriate order – is common sense, but always worth a review. The second requirement about notification is where facilities more frequently run into issues. This was also an issue in the recent past where facilities did not have appropriate orders in place for COVID-19 testing when needed. Hopefully that is something we will have less to worry about in the near future with the PHE schedule to end in May.
Policies & Procedures
It is the responsibility of the facility to develop and implement policies and procedures for lab services that follow current standards of practice. The Interpretive Guidance (IG) notes that the Medical Director should be involved in the development of these P&P.
Policies should include:
- defining clinical reference ranges
- the categories for which abnormal lab values should be reported urgently
- how the effectiveness of communication will be monitored
- if used, how delegation by an ordering practitioner to qualified on-call staff will occur
Surveyors may identify issues with lab orders and reporting during record service. They will be looking to determine if the orders were placed by a provider within scope of practice laws and also if facility staff and the ordering provider were promptly notified of lab results.
Let’s look at a recent survey citation to understand what can be identified:
Recertification Survey Citation – F773 S/S: G (Actual Harm)
A facility was cited under F773 for failure to ensure that for two residents, the MD/NP was notified of lab results timely, which resulted in the delay of altering the course of treatment. The facility did not ensure that for one resident, staff notified the ordering practitioner of a resident’s recurrent, abnormal high glucose levels timely, resulting in the resident being admitted to ICU. For a second resident, it was identified that the resident’s physician was not notified of critical lab results of Cardio C-Reactive Protein (CRP). As a result, the physician did not conduct timely follow up.
A point of clarification to be aware of regarding F773 – this is not where facilities are cited if lab results were not acted on in a timely manner by the practitioner. F773 is predominantly about timely notification – an area where systems often fail. The State Operation Manual (SOM) directs surveyors to considering other regulations that may be applicable, including:
- Medical Director
- Nursing Services
- Quality of Care
- Quality of Life
That means that you could not only be cited under F773 for not sharing lab results timely, but also additional areas depending on the outcome to the resident.
Please remember, a lack of communication of abnormal lab results can result in a deficiency as well as a potential negative outcome for a resident. The practitioner needs to be consistent in writing an appropriate order versus documenting in a progress note that he/she ordered “labs” but doesn’t document the order.