COMAR 10.07.14: Maryland Assisted Living Regulations

Maryland’s assisted living regulations live in COMAR 10.07.14, the chapter of the Code of Maryland Regulations that governs every licensed assisted living program in the state. It sets the rules on who can run a facility, how staff must be trained, what rights residents keep, what the building has to look like, and what happens when a program falls short. Maryland law defines an assisted living program as one that provides housing along with supportive services, health-related care, or personalized help for people who need assistance with daily living.¹

Three Levels of Care

Every Maryland facility is licensed to serve one of three care levels, and it has to choose which one at the application stage.²

Level 1 is for residents who are largely independent and need occasional help with tasks like bathing, dressing, or medication reminders.
Level 2 is for residents who need substantial help with two or more daily activities, or lighter help across many, and whose care may include medication administration and management of frequent behavioral or psychiatric episodes.
Level 3 is for residents with significant physical or cognitive impairments who need intensive, ongoing support across nearly all daily activities, including advanced dementia and chronic medical conditions.

This matters directly for residents. If a resident’s needs rise above the level the facility is licensed for, the program cannot keep them absent a special waiver from the Department of Health, and it must arrange discharge to a program that can provide the higher level.³

Licensing

No one can operate an assisted living program in Maryland without a license from the Office of Health Care Quality (OHCQ), the enforcement arm of the Maryland Department of Health.⁴ Applications must be typed and filed electronically. An applicant has to submit a business plan and a one-year operating budget showing the program can sustain itself, criminal background checks on the owner, manager, alternate manager, all staff, and any household members living on site, and a Uniform Disclosure Statement describing services and costs on a standardized state form.⁵

The applicant also has to show local zoning approval and any required sign-offs from the local health department and fire authority, disclose anyone holding 25 percent or more ownership, and disclose any prior license denials, suspensions, or revocations in care-related fields. A nonrefundable license fee accompanies the application, with annual fees scaled by bed count.

Who Runs the Program and Who Gives the Medications

Every program must designate a manager who is at least 21 and has a high school diploma or equivalent. Level 3 programs demand more: either a four-year college degree, or two years of healthcare experience plus one year as an assisted living manager, or two years of healthcare experience plus completion of the state-approved 80-hour training course.⁶

Regardless of level, every manager completes the 80-hour course, which covers legal responsibilities, clinical care, and administration, and includes an examination. After that, managers take 20 hours of Department-approved continuing education every two years.⁶

Direct care staff go through orientation and ongoing training on fire safety, infection control, resident rights, emergency procedures, and food handling, with personnel files documenting each employee’s completed training.⁷

Medications have their own rule. An unlicensed staff member who will give medications to residents must first complete a medication administration course taught by a registered nurse approved by the Maryland Board of Nursing, and then obtain certification as a medication technician through the Board. Proof of certification stays in the personnel file.⁸

Not every resident is in this category. If someone can recognize their own medications and take them correctly with only a reminder or help opening a container, the rules treat that as self-administration, not medication administration. The initial assessment decides which side of the line a resident is on.⁸

Resident Rights

Every program must adopt a Resident Bill of Rights and give each resident a copy. The core protections cover:⁹

Freedom from mental, verbal, sexual, physical, and financial abuse, from neglect, and from physical or chemical restraints used in violation of the chapter.
Privacy, including staff knocking before entering a resident’s room absent an emergency or a sleeping resident.
Managing one’s own finances to the extent the law allows, or designating a representative.
Filing complaints without retaliation through a formal grievance procedure.
Participating in care planning, choosing a pharmacy provider, and accepting or refusing treatment.
Being told how to reach the Long-Term Care Ombudsman, Adult Protective Services, and OHCQ.

Residents also keep the right to receive visitors, meet privately with legal counsel, send and receive mail without interference, and choose their own clothing and hairstyle.⁹

Service Agreements and Discharge

Before moving in, the resident and the program sign a written service agreement. It must list every service the program provides and every service it does not, the assigned room and bed, the grievance procedure, and the program’s policy on medication self-administration.³

The agreement must also spell out the circumstances that can lead to discharge. A program that wants to discharge someone without their consent has to give at least 30 calendar days of written notice. A hospital transfer by itself is not grounds for discharge; if a hospitalized resident’s needs have advanced past what the facility can provide, the program still has to follow specific procedures before ending the relationship.¹⁰ Residents also have the right to participate in decisions about any transfer or discharge.⁹

Building and Safety Standards

The physical plant rules are specific. A single-occupancy room must have at least 80 square feet of functional space, and a double-occupancy room at least 120. Functional space excludes closets, bathrooms, wardrobes, entrance areas, and the swing arc of any door opening into the room. No room can hold more than two residents.¹¹

Bathroom counts run by ratio. Programs with one to eight occupants need at least one toilet and one hand sink for every four occupants. Programs with nine or more must maintain that ratio and add at least one toilet and one sink on every floor with a resident room. Bathtubs or showers sit in private, enclosed spaces at a rate of at least one per eight occupants.¹²

Safety features include interconnected smoke detectors, emergency lighting, hallway handrails, and grab bars in all bathing areas. Facilities have to comply with the Life Safety Code, the federal fire-protection standard for care settings, and keep maintenance logs showing their safety systems remain functional.¹³

Alzheimer’s Special Care Units

A facility that wants to operate an Alzheimer’s or dementia special care unit needs separate written approval from the Department before it admits residents or even advertises the unit. It submits a disclosure form explaining how the specialized unit differs from its regular program and how the care is designed for people with Alzheimer’s disease or related dementias.¹⁴

Staff carry extra training. Any licensed, certified, or registered staff member whose duties include personal care on the unit must complete at least six hours of advanced cognitive impairment training: two hours on effective communication, two hours on behavioral interventions, and two hours on making activities meaningful. The unit provides annual dementia-specific training for all staff, and residents’ families or representatives get the written unit description before admission.¹⁴

Complaints and Enforcement

OHCQ conducts unannounced surveys and can inspect at any time, often after a complaint. Anyone can file a complaint through OHCQ’s online form, and paper forms are available. Anonymous complaints are accepted, though the complainant’s identity could be revealed if a matter reaches a hearing or trial.¹⁵

When the Department finds violations, the Secretary of Health has broad authority. Sanctions can restrict how many residents a facility can admit, force a reduction in the current census, restrict the levels of care it can offer, require specific staffing patterns, require remedial staff training, and force the facility to hire a Department-approved management firm or consultant at its own expense.¹⁶

Civil money penalties come on top. Fines can run per day for as long as noncompliance continues, or per instance for each violation, and apply to deficiencies, unlicensed operation, and false advertising of services. If a facility violates a sanction the Secretary has already imposed, the license itself can be suspended or revoked.¹⁶

Paying for Care

Medicare does not pay for assisted living. It covers hospital stays, doctor visits, and certain skilled nursing care, but not the room, board, and personal care services at the heart of assisted living. Residents or their families cover 100 percent of those costs.¹⁷

Medicaid can help. Maryland runs the Home and Community Based Options Waiver, which covers assisted living services for adults 65 and older and for adults 18 to 64 with physical disabilities, provided they meet a nursing facility level of care. The waiver also covers case management, medical day care, respite care, and nutrition services.¹⁸ Enrollment is capped, so the state limits how many people can participate at once.¹⁹

The Long-Term Care Ombudsman

Alongside OHCQ, Maryland residents in assisted living have a separate advocate: the Long-Term Care Ombudsman Program, authorized under the federal Older Americans Act.²⁰ Every county has a local ombudsman office. Services are free and confidential, and the ombudsman only acts with the resident’s consent. Contact information is available through the Maryland Department of Aging, and the office is worth knowing about before a problem develops, since ombudsmen also help residents and families understand what a facility should look like in practice.²¹

1
Maryland General Assembly. Maryland Health-General Article 19-1801
2
Library of Maryland Regulations. COMAR Chapter 14 – Assisted Living Programs
3
Library of Maryland Regulations. COMAR Chapter 14 – Assisted Living Programs – Section: Resident Agreement
4
Maryland Department of Health. Assisted Living Providers
5
Legal Information Institute. Maryland Code of Regulations 10.07.14.07 – Licensing Procedure
6
Library of Maryland Regulations. COMAR 10.07.14.15 – Assisted Living Manager
7
Library of Maryland Regulations. COMAR 10.07.14.19 – Other Staff Qualifications
8
Library of Maryland Regulations. COMAR 10.07.14.31 – Medication Management and Administration
9
Legal Information Institute. Maryland Code of Regulations 10.07.14.36 – Residents Rights
10
Library of Maryland Regulations. COMAR 10.07.14.34 – Relocation and Discharge
11
Library of Maryland Regulations. COMAR 10.07.14.42 – General Physical Plant Requirements – Section: Residents Room and Furnishings
12
Library of Maryland Regulations. COMAR 10.07.14.42 – General Physical Plant Requirements – Section: Bathrooms for Residents
13
Centers for Medicare & Medicaid Services. Life Safety Code and Health Care Facilities Code Requirements
14
Legal Information Institute. Maryland Code of Regulations 10.07.14.32 – Alzheimers Special Care Unit
15
Maryland Department of Health. File a Complaint
16
Legal Information Institute. Maryland Code of Regulations 10.07.14.57 – Sanctions
17
Medicare.gov. Long-Term Care
18
Medicaid.gov. Maryland Waiver Factsheet
19
Medicaid.gov. Home and Community-Based Services 1915(c)
20
Office of the Law Revision Counsel. 42 USC 3058g – State Long-Term Care Ombudsman Program
21
Maryland Department of Aging. Long-Term Care Ombudsman