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

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).

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.

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 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; (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.

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.

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).

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.

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