Maryland

Agency

Department of Health, Office of Health Care Quality

Contact

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Website

https://health.maryland.gov/ohcq/Pages/home.aspx

Licensure Term

Assisted Living Programs

Definition

An assisted living program is a residential- or facility-based

program that provides housing and supportive services,

supervision, personalized assistance, health

-related services, or

a combination that meets the needs of residents who are unable

to perfor

m, or who need assistance in performing activities of

daily living (ADLs) or instrumental activities of daily living in a

way that promotes optimum dignity and independence for the

residents.

During the last regulatory update, two assisted living program

definitions were removed from what is not considered an

assisted living program:

(1) emergency, transitional, and permanent housing

arrangements for the homeless, where no assistance with ADLs

is provided; and

(2) emergency, transitional, and permanent housing

arrangements for the victims of domestic violence.

The following definition for what is not considered an assisted

living program was added: a Certified Adult Residential

Environment Program that is certified by the Department of

Human Resource

s under Article 88A, §140, Annotated Code of

Maryland.

Regulatory and Legislative

Update

The Maryland Department of Health (MDH), Office of Health

Care Quality (OHCQ) licenses assisted living programs based on

three

levels of care provided. The regulations do not specify a

minimum number of residents for licensure. However, assisted

living facilities are considered a related institution in Maryland.

Related institutions are defined as having two or more residents.

An assist

ed living facility which is contemplating adding an

Alzheimer’s special care unit is required to notify OHCQ.

There have

been no recent regulatory or legislative updates this

last legislative session.

Facility Scope of Care

Facilities may provide one of three levels of care: low, moderate,

or high. The levels of care are defined by varying service

requirements pertaining to health and wellness; assistance with

functioning; assistance with medication and treatment;

management of behavioral issues; management of psychological

or psychiatric conditions; and social and recreational concerns.

Under low and moderate levels of care, staff must assist with two

or more A

DLs.

If a facility wishes to continue to serve a resident requiring a

higher level of care than that for which the facility is licensed for

more than 30 days, the facility must obtain a resident

-specific

waiver. A waiver requires a showing that the facility can meet the

needs of the resident and not jeopardize other residents. The

licensee shall submit a waiver application as soon as program

staff determine that the increased level of care of the condition

requiring the waiver is likely to exceed 30 days.

Waivers to care

for residents at the moderate and high levels are limited to 50

percent of licensed beds. Waivers to exceed the high level are

limited to 20 percent of licensed beds or up to 20 beds,

whichever is less. If, at any time, a licensee wants to

provide a

higher level of care than that for which it is licensed, the licensee

shall request authority from the department to change its

licensure authority.

Limitations of Services

Facilities may not admit individuals who require more than

intermittent nursing care; treatment of stage III or IV skin ulcers;

ventilator services; skilled monitoring, testing, and aggressive

adjustment of medications and treatments where there is the

pre

sence of, or risk for, a fluctuating acute condition; monitoring

of a chronic medical condition that is not controllable through

readily available medications and treatment; treatment for an

active, reportable communicable disease; or treatment for a

disea

se or condition that requires more than contact isolation. In

addition to these seven conditions, individuals may not be

admitted if they are dangerous to self or others and are at high

risk for health and safety complications that cannot be

adequately man

aged. Facilities may request a resident-specific

waiver for existing residents presenting with one of these

conditions.

Move-in Requirements

Including Required

Disclosures/Notifications

All assisted living providers are required to complete an Assisted

Living Disclosure Form, which must be included in all marketing

materials and made available to consumers upon request. The

form is reviewed during facility surveys, and providers must

noti

fy and file an amendment with the OHCQ within 30 days of

changes in services. Written disclosure also must be made to the

MDH and consumers by assisted living programs offering

Alzheimer's special care units or programs.

Resident Assessment

Requirements and Frequency

A resident’s service plan must be based on assessments of

his/her health, function, and psychosocial status using the

Resident Assessment Tool. Within 30 days before admission,

the assisted living program must collect information about the

potential reside

nt's physical condition and medical status.

A full assessment must also be completed within 48 hours, but

not later than required by the nurse practice act, after a

significant change of condition and each non

-routine

hospitalization. "Significant chang

e 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 decl

ine 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 continue to recur.

When the delegating nurse determines in the nurse's clinical

judgment that the resident does not require a full assessment

within 48 hours, the delegating nurse shall:

(1) document the determination and the reasons for the

determination in the resident's record; and

(2) ensure that a full assessment of the resident is conducted

within seven calendar days.

A review of the assessment shall be conducted every six months

for resident

s who do not have a change in condition. Further

evaluation by a health care practitioner is required and changes

shall be made to the resident's service plan, if there is a score

change in any of the following areas:

(1) cognitive and behavioral status;

(2) ability to self

-administer medications; and

(3) 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 shall include documenta

tion as to whether

awake overnight staff is required due to a change in the

resident's condition.

Medication Management

The assisted living manager and all staff who administer

medications must have completed the medication administration

course taught by a registered nurse who is approved by the

Board of Nursing.

An assisted living manager must arrange for a licensed

pharmacist to conduct an on-site review of physician

prescriptions, orders, and resident records at least every six

months for any resident receiving nine or more medications,

including over

-the-counter and PRN medications. The regulation

specifies what mu

st be examined during the review and that the

review must be part of the quality assurance review. There is

also a requirement that all schedule II and III narcotics must be

maintained under a double

-lock system and staff must count

controlled drugs before

the close of every shift.

Staffing Requirements

A staffing plan must be submitted to OHCQ which demonstrates

that there will be on

-site staff sufficient in number and

qualifications to meet the 24

-hour scheduled and unscheduled

needs of the residents. When a resident is in the facility, a staff

member s

hall be present. There are no staffing ratios. An

alternate assisted living manager shall be present on site or

available on call when the assisted living manager is unavailable.

An assisted living program shall provide awake overnight staff

when a resi

dent's assessment using the Resident Assessment

Tool indicates that awake overnight staff is required. If a

physician or assessing nurse, in his/her clinical judgment, does

not believe that a resident requires awake overnight staff, the

physician or assess

ing nurse shall document the reasons in the

area provided in the Resident Assessment Tool which shall be

retained in the resident's record.

Upon the written recommendation of the resident's physician or

assessing nurse, the assisted living program may a

pply to the

department for a waiver to use an electronic monitoring system

instead of awake overnight staff.

Administrator/Director

Education and Training

Requirements

The assisted living manager must be at least 21 years of age

and possess a high school diploma or equivalent and have

sufficient skills, training, and experience to serve the residents in

a manner that is consistent with the philosophy of assisted living

(

delineated in regulation). For a high level of care program, an

assisted living manager must have a four

-year, college-level

degree; two years of experience in a health care related field and

one year of experience as an assisted living program manager or

alternate assisted living manager; or two years of experience in a

health care related field and successful completion of an 80

hour

assisted living manager training program. The 80

-hour training

program must be approved by the OHCQ and cover required

cont

ent on aging, cognitive impairment, and dementias.

Direct Care Staff Education

and Training Requirements

Staff other than the manager and alternate manager must be at

least 18 years of age unless licensed as a nurse or the age

requirement is waived by MDH. Staff whose duties include

personal care must complete a state

-approved, five hours of

training on cognitive impairment and mental illness within the first

90 days of employment. Staff whose job duties do not involve the

provi

sion of personal care services shall receive a minimum of

two hours of training on cognitive impairment and mental illness

within the first 90 days of employment. Staff must participate in

an orientation program and ongoing training to ensure that

resident

s receive services consistent with their needs.

Staff shall demonstrate competence to the delegating nurse

before performing personal care services and may work for

seven days before demonstrating such competency to provide

personal care services if the employee is performing tasks

accompanied by a cert

ified nursing assistant, a geriatric nursing

assistant, or an individual who has been approved by the

delegating nurse.

At least two hours of ongoing training must be provided annually

for those involved with the provision of personal care. For those

not involved with the provision of personal care, at least one hour

of training per year is required.

Quality Requirements

The assisted living program must develop and implement a

quality assurance plan. The assisted living manager and the

delegating nurse shall meet at least every 6 months to review the

hange in status of the program's residents; outcomes of

pharmacy reviews;

service plan requirements; and written

recommendations or findings of the consultant pharmacist, as

required by Regulation .29J of this chapter. The assisted living

manager

will document the proceedings of the meeting held.

Infection Control

Requirements

There are no specific infection control requirements detailed

other than to follow stand precautions related to infection control.

Emergency Preparedness

Requirements

The assisted living program shall develop an emergency and

disaster plan that includes procedures that shall be followed

before, during, and after an emergency or disaster, including:

(a) Evacuation, transportation, or shelter in

-place of residents;

(b) Notification of families and staff regarding the action that will

be taken concerning the safety and well

-being of the residents;

responsibilities for ongoing shelter in

-place or evacuation,

including ident

ification of staff members available to report to

work or remain for extended periods; and

(d) The continuity of services, including:

(i) Operations, planning, financial, and logistical arrangements;

(ii) Procuring essential goods, equipment, and services to

sustain operations for at least 72 hours;

(iii) Relocation to alternate facilities or other locations; and

(iv) Reasonable efforts to continue care.

(2) The licensee shall have a tracking system to locate and

identify residents in the event of displacement, an emergency, or

a disaster that includes at a minimum the:

(a) Resident's name;

(b) Time that the resident was sent to the initial alternative facility

or location; and

resident was sent.

(3) When the assisted living program

relocates residents, the

program shall send a brief

medical fact sheet with each resident

that includes at a minimum the resident's:

(a) Name;

(b) Medical condition or diagnosis;

(d) Allergies;

(e) Special diets or dietary restrictions; and

(f) Family or legal representative contact information.

(4) The brief medical fact sheet for each resident shall be:

(a) Updated upon the occurrence of change in any of the

required information;

(b) Reviewed at least monthly; and

available to a

ccompany residents in case of an emergency

evacuation.

(5) The licensee shall review the emergency and disaster plan at

least annually and update the plan as necessary.

(6) The licensee shall:

(a) Identify a facility, facilities, or alternate location or locations

that have agreed to house the licensee's residents during an

emergency evacuation; and

(b) Document an agreement with each facility or location.

(7) The licensee shall:

(a) Identify a source or sources of transportation that have

agreed to s

afely transport residents during an emergency

evacuation; and

(b) Document an agreement with each transportation source.

(8) Upon request, a licensee shall provide a copy of the facility's

emergency and disaster plan to the local emergency

management organization for the purpose of coordinating local

emergency planning. The licensee shall provide the emergency

and disaster plan in a format that is mutually agreeable to the

local emergency management organization.

(9) The licensee shall identify an emergency and disaster

planning liaison for the facility and shall provide the liaison's

contact information to the local emergency management

organization.

(10) The licensee shall prepare an executive summary of its

evacuation procedures to pro

vide to a resident, family member,

or legal representative upon request. The executive summary

shall, at a minimum:

(a) List means of potential transportation to be used in the event

of evacuation;

(b) List potential alternative facilities or locations to be used in

the event of evacuation;

legal representatives;

(d) Describe the role of the resident, family member, or legal

representative in the event of an emergency situation; and

(e) Notify fami

lies that the information provided may change

depending upon the nature or scope of the emergency or

disaster.

Life Safety Requirements

Facilities must abide by the National Fire Protection Association

Life Safety Code 101 and must have hand extinguishers and an

emergency plan known to all staff. Smoke detectors must be

installed in all sleeping rooms, on each level of the dwelling

includi

ng basements, and outside of each sleeping area, in the

immediate vicinity of the sleeping rooms. The plan for fire

evacuation must be posted on all floors. Fire drills must be

conducted. The plan for fire evacuation must be posted on all

floors. Fire dril

ls must be conducted quarterly on every shift and

documented. A disaster drill must be conducted and written up

annually. Table

-top drills are acceptable if it can be shown that

actually performing the drill would unduly risk the health and

safety of parti

cipants.

The regulations require emergency preparedness plans to

address the evacuation, transportation, or shelter in place of

residents; notification to families, staff, and the OHCQ regarding

the action that will be taken concerning the safety and wel

being

of the residents; staff coverage, organization, and assignment of

responsibilities; and the continuity of operation, including

procuring essential goods, equipment, and services, and

relocation to alternative facilities (methods of transportation must

be identified but need not be guaranteed).

Assisted living programs providing services to 50 or more

individuals must have on premises an emergency back

-up

generator in working condition and capable of running for 48

hours. Exemptions are allowed for facilities that can demonstrate

financial hardsh

ip and waivers for facilities connected by a

corridor to a facility with a generator.

Medicaid Policy and

Reimbursement

Maryland has a Section 1915(c) home and community-based

services waiver, Home and Community

-Based Options, that

covers services in applicable assisted living programs.

Participants must be assessed to need a nursing facility level of

care based on a unifor

m medical assessment, meet financial

eligibility requirements, and be aged 18 years old or older. They

must be provided with 24

-hour supervision, and facilities must

employ a delegating nurse (a registered nurse) to visit every 45

days.

Citations

Code of Maryland Regulations. (2021) Title 10. Maryland

Department of Health, Part 1, Subtitle 07. Hospitals. Chapter

10.07.14. Assisted Living Programs.

http://mdrules.elaws.us/comar/10.07.14

Department of Health. (n.d.) Home and Community

-Based

Services.

https://mmcp.health.maryland.gov/waiverprograms/pages/home.

aspx

HB1034 (2022)

https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/hb1

034?ys=2022RS

HB0720 (2022)

https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/SB0

720?ys=2022RS

HB0636 (2022)

https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/HB0

636?ys=2022RS

SB0531 (2022)

https://mgaleg.maryland.gov/mgawebsite/Legislation/Details/SB0

531?ys=2022RS