MD-1
Compendium of Residential Care and Assisted Living Regulations and Policy: 2015 Edition
MARYLAND
Licensure Terms
Assisted Living Programs
General Approach
The Department of Health and Mental Hygiene licenses three types of assisted
living programs (ALPs) based on the level of care provided. The state does not specify
a minimum number of residents for ALP licensure.
Adult Foster Care (AFC). The state licenses two types of AFC. (1) AFC provides a
family setting in the community for an aged adult or an adult with disabilities who
requires protective oversight, assistance with the activities of daily living (ADLs), and
room and board. AFC is administered by local departments of social services.
(2) Certified Adult Residential Environment (CARE) programs licenses individuals to
provide--in their own homes--room and board, assistance, and supervision to adults
with disabilities who are capable of living in the community but are unable to live alone.
The program, also known as Project Home, is a voluntary program that develops,
certifies, and monitors protective CARE housing for individuals with disabilities; provides
case management services to residents living in CARE housing; and provides a long-
term or permanent housing setting for a stable population of individuals with disabilities
using an adult foster family model of care. Regulatory provisions for these settings are
not included in this profile but a link to the provisions can found at the end.
This profile includes summaries of selected regulatory provisions for ALPs. The
complete regulations are online at the links provided at the end.
Definitions
Assisted living program means a residential or facility-based program that
provides housing and supportive services, supervision, personalized assistance, health-
related services, or a combination thereof to meet the needs of residents who are
unable to perform, or who need assistance with, ADLs and/or instrumental activities of
daily living. Programs can be licensed to provide three levels of care: Level 1 (low),
Level 2 (moderate), or Level 3 (high).
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Resident Agreements
Resident agreements must include information about the facility’s level of care
licensure; a list of services provided and not provided and the services that the resident
will receive; rights and responsibilities of the facility and residents; the terms and
conditions of continued occupancy/discharge; grievance procedures; occupancy
provisions and policies (e.g., regarding room assignment, relocation, and changes in
roommates); and the obligations of all parties for arranging for and overseeing medical
care and monitoring health status.
Financial information must also be provided in the resident agreement, including
rate, payment, and refund policies; policies and procedures for arranging and
contracting for services the facility does not provide; and notification requirements for
changes. If a residents’ needs change significantly, the agreement must be amended.
The agreement must also include a recommendation for review by an attorney.
Disclosure Provisions
Programs must complete a Department-approved Assisted Living Disclosure Form
that must be included in all marketing materials and made available to consumers upon
request. The form is reviewed during facility surveys, and providers must notify the
Office of Health Care Quality if they have changed the services that they will furnish.
Programs with an Alzheimer’s special care unit must complete the Department’s
disclosure form that describes the following:
• A statement of philosophy or mission.
• Staff training and job titles.
• Admission and discharge procedures.
• Assessment and care planning protocols.
• A description of the physical environment and any unique design features
appropriate to support the functioning of cognitively impaired individuals.
• A description of activities, including frequency and type, how they meet the
needs of residents with dementia, and how the activities differ from those for
residents in other parts of the program.
• Fees for services provided.
• Any services, training, or other procedures that are over and above those that
are provided by the ALP.
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Admission and Retention Policy
Programs may not admit individuals who require: (1) more than intermittent nursing
care; (2) treatment of Stage III or IV skin ulcers; (3) ventilator services; (4) skilled
monitoring, testing, and close monitoring and adjustment of medications and treatments
where there is the presence of, or risk for, a fluctuating acute condition; (5) monitoring of
a chronic medical condition that is not controllable through readily available medications
and treatments; (6) treatment for an active reportable communicable disease; or
(7) treatment for a disease or condition that requires more than contact isolation.
Individuals may also not be admitted if they are a danger to self or others and the
danger cannot be eliminated through appropriate treatment modalities, or if they are at
risk for health or safety complications that cannot be adequately managed.
Programs may request a waiver to care for residents whose needs exceed the
licensure level. Approval is based on the facility’s demonstrated ability to meet the
resident’s needs without harm to other residents. The number of waivers granted to a
facility is limited.
Services
Level 1 programs must provide: (1) assistance in accessing and coordinating
health services; (2) supervision or occasional assistance with two or more ADLs; (3)
assistance with self-administration of medications; (4) uncomplicated interventions to
manage occasional behaviors that might disrupt or harm the resident or others;
(5) monitoring and management of occasional psychological or psychiatric episodes or
fluctuations that require uncomplicated intervention or support; and (6) occasional
assistance in accessing social and recreational services. The Medicaid waiver program
does not cover services in Level 1 programs.
Level 2 programs provide all Level 1 services and also substantial support with two
or more ADLs; medication administration, including monitoring the effects of the
medication and treatment; monitoring and providing intervention to manage frequent
behaviors that are likely to disrupt or harm the resident or others; monitoring and
managing frequent psychological or psychiatric episodes that may require prompt
intervention or support; and ongoing assistance in accessing social and recreational
services.
Level 3 programs provide all Level 2 and 3 services and also ongoing access to
and coordination of comprehensive health services and interventions; comprehensive
and frequent assistance with ADLs; monitoring and providing ongoing therapeutic
intervention or intensive supervision to manage chronic behaviors that might disrupt or
harm the resident or others; and monitoring and managing a variety of psychological or
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psychiatric episodes involving active symptoms, condition changes, or significant risks
that may require skilled interpretation or immediate interventions.
Service Planning
Programs must assess individuals to identify the appropriate level of care needed
to meet needs related to medical illnesses/conditions and cognitive and psychiatric
conditions; treatment requirements; ability to self-administer medication; ADL needs;
risk factor management needs; and problematic behaviors.
The assessment must be reviewed every 6 months. A full assessment is required
after a significant change of condition and each non-routine hospitalization. Significant
change of condition means a resident has demonstrated major changes in status that
are not self-limiting or which cannot be resolved within 30 days; a change in one or
more areas of the resident’s health condition that could demonstrate an improvement or
decline in the resident’s status; and the need for interdisciplinary review or revision to
the service plan. A significant change of condition does not include any ordinary, day-to-
day fluctuations in health status, function, or behavior, or an acute short-term illness
such as a cold, unless these fluctuations recur on an ongoing basis.
Evaluation by a health care practitioner is required and changes must be made to
the resident's service plan if there is an assessment score change in any of the
following areas: cognitive and behavioral status; ability to self-administer medications;
and/or behaviors and communication. If the resident's previous assessment did not
indicate the need for awake overnight staff, each full assessment or review of the full
assessment must document whether awake overnight staff are required due to a
change in the resident's condition.
Third-Party Providers
Home health and hospice agencies may provide services through direct contracts
with residents.
Medication Provisions
Programs may provide assistance with self-administration of medications or may
administer medications. Assistance with self-administration includes reminders to take
medications and/or physical assistance to open and remove medications from a
container. Residents’ ability to self-administer must be reviewed at least quarterly by a
licensed health professional. Staff who have passed a Board of Nursing program may
administer medications.
A licensed health professional must review each resident’s medication regime
within 14 days of admission in order to: (1) verify the resident's current medication
profile, including all prescription and non-prescription medications and tube feedings;
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(2) identify the potential that current medications have to act as chemical restraints; (3)
identify the potential for any adverse drug interactions, including potential side effects
from the medications; and (4) identify any medication errors that have occurred since
admission.
In addition, programs must arrange for a licensed pharmacist to conduct an on-site
review of physician’s prescriptions, orders, and residents’ records at least every 6
months for any resident receiving nine or more medications, including over-the-counter
and as-needed medications. The purpose of the review is described in detail and
includes topics such as proper packaging and storage, physicians’ orders, whether
prescribed medications appear to be effective, errors, adverse effects, inappropriate
treatment, overuse, and potential drug interactions. Residents’ providers must be
informed about negative findings.
Food Service and Dietary Provisions
Programs must provide three meals a day and snacks that are well-balanced,
palatable, varied, properly prepared, and of sufficient quantity and quality to meet daily
nutritional needs. A licensed nutritionist or licensed dietician must review menus on a 4-
week cycle for nutritional quality. Programs must also provide special diets as ordered
by a physician or needed by residents. Residents must have access to snacks or food
supplements during the evening hours.
Staffing Requirements
Type of Staff. A manager is required to direct daily operations, and an alternate
manager must be identified when the manager is unavailable. The facility must have a
signed agreement with a registered nurse (RN) and/or employ an RN to provide
required nursing services, including delegation of nursing tasks. The facility must
provide on-site nursing when a delegating nurse or physician, based upon the needs of
a resident, issues a nursing or clinical order for that service. Staff must include
medication technicians who have completed required medication administration training
and direct care staff to assist residents with personal care.
Staff Ratios. No minimum ratios. Staff sufficient in number and qualifications to
meet residents’ 24-hour scheduled and unscheduled needs are required. Awake
overnight staff may not be required if a physician or nurse determines that residents do
not require overnight assistance. The facility must apply to the Department for a waiver
to use an electronic monitoring system in place of awake overnight staff.
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Training Requirements
Managers of programs licensed for five or more residents must complete 20 hours
of Department-approved continuing education every 2 years.
Staff must receive initial and ongoing training in fire and life safety; infection
control, including standard precautions; basic food safety; basic first-aid; emergency
disaster plans; and their individual job requirements. Staff must have knowledge in
health and psychosocial needs of the population served as appropriate to their job
responsibilities; the resident assessment process; the use of service plans; and
residents’ rights.
Staff whose duties include personal care must complete a state-approved, 5-hour
training on cognitive impairment and mental illness within the first 90 days of
employment. Staff must demonstrate competence to the delegating nurse before
performing personal care services.
Provisions for Apartments and Private Units
Apartment-style units are not required. A maximum of two residents is allowed per
resident unit; however, this limit may be waived by the state agency for existing
programs that have previously received a waiver. Programs must have a minimum ratio
of one toilet for every four residents. Buildings with nine or more residents must have at
least one toilet for four residents on each floor where a resident is located. A minimum
of one bathtub or shower is required for every four residents in facilities with 1-8
residents and one for every eight residents in larger facilities.
Provisions for Serving Persons with Dementia
Dementia Care Staff and Facility Requirements. No provisions identified.
Dementia Staff Training. Staff must receive a minimum of 5 hours of training on
cognitive impairment and mental illness within 90 days of employment. The training
content must be designed to meet specific resident’s needs as determined by the
manager.
At least 2 hours of ongoing training must be provided annually for staff who provide
personal care. Training can be provided through classroom instruction, in-service
training, Internet courses, correspondence courses, pre-recorded training, or other
methods.
MD-7
Background Checks
Before licensure, the applicant must document any convictions and provide the
results of a current criminal background check or criminal history records check of the
owner, applicant, assisted living manager, alternate assisted living manager, other staff,
and any household member (for small owner-occupied homes). The manager must
conduct a criminal background check or criminal history records check of all prospective
employees.
Inspection and Monitoring
Inspections occur every 15 months or more often, as needed. The Department of
Health and Mental Hygiene may delegate inspection and monitoring of programs to the
Department of Aging or to local health departments through an interagency agreement.
Public Financing
The state covers services in Level II and Level III ALPs for individuals age 50 and
older under the Medicaid 1915(c) Home and Community-Based Options Waiver
program (formerly the Waiver for Older Adults, now merged with the Living at Home
Waiver).
1
In addition, the state-funded Senior Assisted Living Group Home Subsidy program
provides subsidies for services in small assisted living facilities licensed for 4-16
residents. The subsidy supports the cost of services provided, including meals, personal
care, and 24-hour supervision for elderly residents who are frail and unable to live
independently.
Room and Board Policy
In 2014, the Department of Aging paid the difference between a resident’s income
and the monthly facility rate--after deducting $68 a month for personal needs--up to a
maximum of $650 a month. In 2009, family supplementation was not permitted.
2
1
See http://aging.maryland.gov/MedicaidWaiverServices.html.
2
Mollica, R.L. (2009). State Medicaid Reimbursement Policies and Practices in Assisted Living, National Center for
Assisted Living, American Health Care Association.
http://www.ahcancal.org/ncal/resources/Documents/MedicaidAssistedLivingReport.pdf
. Current information about
family supplementation policy was not available online or from other sources.
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Location of Licensing, Certification, or Other Requirements
Annotated Code of Maryland, Title 10, Subtitle 07, Chapter 14: Assisted Living Programs
Authority: Health-General Article, Title 19, Subtitle 18.
http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=10.07.14
Annotated Code of Maryland, Title 07, Subtitle 02, Chapter 17: Adult Foster Care Authority.
http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=07.02.17
Annotated Code of Maryland, Title 07, Subtitle 02, Chapter 19: Certified Adult Residential
Environment (CARE) Program Authority.
http://www.dsd.state.md.us/comar/SubtitleSearch.aspx?search=07.02.19
Department of Aging website: Senior Assisted Group Home Subsidy Program, including
information and links regarding funding of assisted living.
http://www.aging.maryland.gov/SeniorGrpHomeSubsidy.html
Information Sources
Dakota Burgess
Maryland Department of Aging
COMPENDIUM OF RESIDENTIAL CARE AND ASSISTED
LIVING REGULATIONS AND POLICY: 2015 EDITION
Files Available for This Report
FULL REPORT
Executive Summary http://aspe.hhs.gov/execsum/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-executive-
summary
HTML http://aspe.hhs.gov/basic-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition
PDF http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition
SEPARATE STATE PROFILES
[NOTE: These profiles are available in the full HTML and PDF versions, as well as each state
available as a separate PDF listed below.]
Alabama
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-alabama-profile
Alaska http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-alaska-profile
Arizona http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-arizona-profile
Arkansas http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-arkansas-profile
California
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-california-profile
Colorado http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-colorado-profile
Connecticut http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-connecticut-profile
Delaware
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-delaware-profile
District of Columbia http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-district-columbia-
profile
Florida
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-florida-profile
Georgia http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-georgia-profile
Hawaii
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-hawaii-profile
Idaho
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-idaho-profile
Illinois http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-illinois-profile
Indiana http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-indiana-profile
Iowa http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-iowa-profile
Kansas
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-kansas-profile
Kentucky http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-kentucky-profile
Louisiana
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-louisiana-profile
Maine
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-maine-profile
Maryland http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-maryland-profile
Massachusetts http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-massachusetts-
profile
Michigan http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-michigan-profile
Minnesota http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-minnesota-profile
Mississippi http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-mississippi-profile
Missouri http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-missouri-profile
Montana http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-montana-profile
Nebraska
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-nebraska-profile
Nevada http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-nevada-profile
New Hampshire http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-new-hampshire-
profile
New Jersey http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-new-jersey-profile
New Mexico http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-new-mexico-profile
New York http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-new-york-profile
North Carolina http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-north-carolina-
profile
North Dakota http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-north-dakota-
profile
Ohio
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-ohio-profile
Oklahoma http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-oklahoma-profile
Oregon http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-oregon-profile
Pennsylvania
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-pennsylvania-
profile
Rhode Island
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-rhode-island-
profile
South Carolina
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-south-carolina-
profile
South Dakota http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-south-dakota-
profile
Tennessee
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-tennessee-profile
Texas http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-texas-profile
Utah
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-utah-profile
Vermont
http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-vermont-profile
Virginia http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-virginia-profile
Washington http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-washington-profile
West Virginia http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-west-virginia-
profile
Wisconsin http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-wisconsin-profile
Wyoming http://aspe.hhs.gov/pdf-report/compendium-residential-care-and-
assisted-living-regulations-and-policy-2015-edition-wyoming-profile
