Maryland assisted living program license: OHCQ levels, rules and steps

Two residents is the threshold, and a lease is not a loophole

Maryland defines an assisted living program as “a residential or facility-based program for two or more residents” that provides housing plus supportive services, supervision, personal help, health-related services, or a mix of these to people who need help with activities of daily living or instrumental activities of daily living.⁠¹ So one license type covers everything from a two-bedroom house to a large campus. COMAR 10.07.14 has no separate tier for small homes. A rowhouse with three residents follows the same chapter, COMAR 10.07.14, as a 120-bed building, though some physical plant rules ease below 9 or 17 beds (see below).

Three points in the rule catch founders out:⁠¹

• Housing under a lease still counts. Providing housing under a landlord-tenant arrangement “does not, in and of itself, exclude” you from licensure.
• Every site needs its own license. This applies even when one owner runs two houses on the same street.
• The resident count is broad. The bed limit on your license counts residents in the building, short-term stays, people moving in over a transition period, and family members who are cared for by your staff.

The definition leaves out nursing facilities, State facilities, licensed hospice programs, care given by family members, and services that a licensed residential service agency or home health agency gives in a person’s own home.⁠¹ If your plan is to send aides into clients’ own homes rather than house them, look at the residential service agency license or the home health agency license instead. The rule also excludes a Certified Adult Residential Environment (CARE) program certified by the Department of Human Services.⁠¹

Running a program without a license is a felony if you do it knowingly and willfully. The penalty is a fine of up to $10,000, up to 5 years in prison, or both for a first offense, and up to $20,000 for a later offense.⁠⁵ If OHCQ investigates a credible report of an unlicensed home and finds no abuse, neglect or exploitation, it gives the operator 30 days to come into compliance. An operator who promptly and in good faith files a complete application, is waiting for a decision, and has never been denied a license before is not prosecuted under that provision.⁠⁵ OHCQ has an online form for reporting suspected unlicensed facilities and publishes notices of final action against licensed and unlicensed providers.⁠²

You may not use the words “assisted living” in advertising until you are licensed. Even once licensed, you may not use “hospital”, “sanitarium”, “nursing”, “convalescent”, “rehabilitative”, “sub-acute” or “hospice” in your name or advertising.⁠¹

The rules were rewritten in April 2025

COMAR 10.07.14 was revised effective April 28, 2025.⁠¹ OHCQ describes this as an “extensive revision”.⁠² Older guidance, sample policies, and course materials written before that date may cite section numbers and requirements that no longer exist. OHCQ keeps a page of information and training materials on the new chapter. As of October 12, 2026 it lists no date for its next in-person new-provider orientation.⁠²⁠⁴ The second big change came on July 1, 2026, when assisted living managers had to start holding their own license (covered below).⁠⁹

Choosing your level of care

When you first apply, you ask for one of three levels of care. You must show that you can deliver it, either directly or by coordinating community services.⁠¹ Your license lists that level. You may serve residents at that level and any lower one, but going higher needs OHCQ’s approval first.⁠¹ OHCQ can approve or deny the level you ask for, and you can appeal a denial.⁠¹

Scroll the table sideways to see every column.

The level you choose affects other requirements too. A Level 3 program’s manager needs more education or experience. Also, the Medicaid waiver rate table in COMAR 10.09.54 lists only Level II and Level III assisted living (see the payment section).⁠¹⁠¹¹

Some residents are off-limits whatever your level. You may not admit anyone who, at their first assessment, would need more than intermittent nursing care, treatment of stage three or four skin ulcers, ventilator services, skilled monitoring and frequent adjustment of medications for a fluctuating acute condition, or monitoring of a chronic condition that readily available treatment cannot control.⁠¹ These limits do not apply when a licensed general hospice program provides the services.⁠¹ To keep a resident whose needs have grown past your licensed level, you need a resident-specific waiver approved in writing by OHCQ.⁠¹

Alzheimer’s Special Care Unit

A secured or separate dementia unit is not a separate license. It does need OHCQ’s written approval before you operate it, and before you advertise or market it.⁠¹ You request approval with a disclosure form describing the unit. The description must cover the unit’s philosophy, how its services differ from the rest of the program, admission and discharge criteria, the 24-hour direct-care staffing ratio, use of awake overnight staff, design features, activities, and the unit’s fee structure.⁠¹ Staff who are licensed or certified, or who give personal care on the unit, need at least 6 hours of advanced cognitive impairment training: 2 hours on communication, 2 on behavioral interventions and 2 on meaningful activities.⁠¹ Awake overnight staff are mandatory on the unit, and OHCQ will not waive that requirement for an Alzheimer’s unit.⁠¹ OHCQ decides on later substantive changes to the unit within 30 calendar days of receiving the revised description.⁠¹

The manager: licensed by the Board since July 1, 2026

Effective July 1, 2026, a person must hold a license from the Board of Long-Term Care Administrators before working as an assisted living manager in Maryland.⁠⁹ The Board opened its online application portal on April 20, 2026.⁠⁹ It sorts applicants into two categories:⁠⁹

• Applicant I: people who worked as an assisted living manager in a licensed Maryland program before July 1, 2026.
• Applicant II: everyone else, which includes most founders hiring a first-time manager.

An Applicant II must:⁠¹⁰

• be at least 21 and of good moral character
• have a high school diploma or equivalent
• have completed the 80-hour assisted living manager training course and passed its exam, unless you are employed by a program, enrolled in the course and expect to finish within 6 months, or are a Maryland-licensed nursing home administrator (an enrolled applicant must then finish the course and exam within 6 months of enrollment)
• submit a passport-size photograph taken within 3 months before the application
• submit to a State and national (FBI) criminal history records check
• attest to valid first aid and hands-on CPR certification
• attest to training in fire and life safety, infection control, emergency disaster plans and basic food safety

The Board’s page lists a $100 non-refundable application fee and a $200 license fee, due after approval. Processing takes 10 business days, starting once the fee and all documents, including the background reports, have arrived.⁠⁹

For a Level 3 program, the manager must also have one of these:⁠¹⁠¹⁰

• a 4-year college degree
• 2 years in a health-care-related field plus 1 year as an assisted living manager or alternate manager
• 2 years in a health-care-related field plus the 80-hour course

The 80-hour course must be approved by the Department and end with an exam. It can be taught in person, online, or both.⁠¹⁠⁶ The course includes 20 hours of clinical management and 12 hours of dementia, mental health and behavior management.⁠¹ OHCQ lists the approved course vendors.⁠² After that, the manager needs 20 hours of Department-approved continuing education every 2 years.⁠¹⁠⁶ Licensed nursing home administrators are exempt from the course requirement.⁠⁶ A program that fails to employ a qualified manager risks sanctions and a civil money penalty of up to $10,000.⁠¹⁠⁶

The manager must also complete a criminal history or background check within 1 month before starting, be free of communicable tuberculosis, and show immunity to measles, mumps, rubella and varicella.⁠¹ They must be on site or on call.⁠¹ They are responsible for the staffing plan, the policies, service plans, records, and acting on the delegating nurse’s orders.⁠¹

You also need an alternate assisted living manager. This person must be at least 21, have 2 years of experience in a health-related field, and meet the same screening and training rules as other staff.⁠¹

The delegating nurse

Every program must have a signed, unexpired agreement with a registered nurse who serves as the delegating nurse. If the nurse is your employee, a job description can serve as the agreement.⁠¹ You must keep proof that the nurse finished the Board of Nursing’s mandatory delegating nurse course.⁠¹ The nurse must:⁠¹

• observe each resident on site at least every 45 calendar days
• be on call at all times, or arrange a qualified alternate
• issue nursing and clinical orders
• review the manager’s resident assessments

The manager and delegating nurse must meet at least every 6 months to review changes in residents’ status, service plans, and pharmacy review findings.⁠¹ If the manager refuses a nursing order without documenting a safe alternative, the nurse must report it to the resident’s practitioner, the resident and OHCQ.⁠¹ The application form asks for the nurse’s name, license number and expiration date.⁠³ At the survey, OHCQ checks the nurse’s license, delegating nurse training, and signed contract.⁠³

Staffing: a plan, not a ratio

COMAR 10.07.14 sets no fixed staff-to-resident ratio. Instead, you write a staffing plan based on how many residents you will serve and what each one needs. The plan must cover the 24-hour scheduled and unscheduled needs of residents.⁠¹ There are some firm rules:⁠¹

• A staff member must be present whenever a resident is in the building or is expected back.
• You must keep a staffing schedule on site and retain it for 18 months.
• You must have relief staff available.
• You must have enough CPR-trained staff that someone can perform CPR promptly, 24 hours a day.

Awake overnight staff are required when a resident’s score on the state’s Resident Assessment Tool calls for it. If a practitioner or assessing nurse decides otherwise, the reasons must be written on the tool.⁠¹ OHCQ can waive the requirement if you show that an electronic monitoring system works, except on an Alzheimer’s unit.⁠¹ Practitioners and the delegating nurse can also order on-site nursing for a resident, and failing to carry out such an order can lead to sanctions.⁠¹

Staff rules:⁠¹

• Age. Direct care staff must be 18 or older. The exception is 16- and 17-year-olds who are certified nursing assistants, or who are in a certified nursing assistant course and supervised until certified.
• Background check. Each new hire needs a check completed within 30 calendar days before they start.
• Recurring training. Staff need initial and annual training, and first aid certification renewed every 2 years. Licensed nurses are exempt from the first aid requirement.
• Personal care competence. Staff who give personal care, other than CNAs and GNAs, must show the delegating nurse they can do it. Until then, they may work for up to 10 days if a CNA, a GNA or a nurse-approved person is with them.
• Dementia and mental health training. Personal care staff need 6 hours of initial training on cognitive impairment, mental illness and behavioral health, then 2 hours each year. Other staff need 2 hours of initial training and 1 hour each year.
• Medication. Unlicensed staff who give medication must first complete the medication course taught by a Board of Nursing-approved registered nurse and be certified as medication technicians.

Building and fire safety

Your building must meet local fire and building codes and the NFPA 101 Life Safety Code. Maryland incorporates the 2018 edition. If the building is a one- or two-family dwelling, Chapter 24 of NFPA 101 applies.⁠¹ You cannot use space heaters unless the State or local fire authority approves them.⁠¹ You need fire drills every quarter on all shifts. You also need a disaster drill every six months on all shifts, so that you practice both evacuating and sheltering in place at least once a year.⁠¹ Your emergency plan must name alternate locations and transportation that have agreed to take residents in an evacuation, and plan for at least 72 hours of supplies.⁠¹

Bedrooms cannot be reached only through a bathroom or another bedroom, and residents must not have to go outdoors to reach the living or dining room.⁠¹ At 17 or more beds, residents also must not have to pass through a kitchen.⁠¹ Residents get three meals a day in a common dining area, plus snacks.⁠¹

What changes at 17 beds

Seventeen beds is where Maryland adds a layer of review:

• Approval to build. Programs serving 17 or more residents must also meet Health-General § 19-311.⁠¹ That section requires the Secretary’s approval before you build a “hospital or related institution” or make changes that affect its structure or bed capacity.⁠⁸
• Site plan. Below 17 beds, OHCQ accepts a blueprint or a hand-drawn sketch, with each floor on its own 8.5 x 11 sheet and every room labeled with its measurements and purpose. At 17 or more beds, you need an approved physical site plan review from a Maryland State engineer.⁠³
• Food service. At 17 or more beds, you must follow the food service facility rules in COMAR 10.15.03 and send OHCQ a food service permit from the local health department.⁠¹⁠³
• Public restrooms. Larger programs must also provide public restrooms.⁠¹

Before you apply: property, HOA and local approvals

OHCQ’s application asks for proof that the building is “owned, leased, or otherwise under the control of the applicant”.⁠³ It also asks whether the property is in a common ownership community: a development with a homeowners’ association, a condominium, or a housing cooperative. If it is, you must submit every written approval the community requires before the application is accepted.⁠³ This is the first thing to check before signing for a house in a subdivision.

Depending on where you are, the rule also calls for:

• zoning approval
• approvals from the local health department, the local or State fire authority, and the local area agency on aging
• facility plan review documents
• a rental license.⁠¹

Step two of OHCQ’s process asks for a use and occupancy permit or zoning approval from your local jurisdiction and an approved fire inspection report.⁠³ Programs of 1-16 beds in Baltimore City must submit an environmental report from the Baltimore City Health Department, and programs in Baltimore County must submit one from the county Department of Health.⁠³

Applying to OHCQ: the three steps

OHCQ splits licensing into three steps and asks you not to start step two until its staff tell you step one is complete.⁠³ The form must be typed; handwritten applications are returned. You submit it through the “Submit a License Application” link on the OHCQ website.⁠³⁠⁴

1. Step one: application and attachments. The application asks for:

   • the bed count and the highest level of care you will offer
   • whether you will run an Alzheimer’s unit
   • whether construction is finished
   • the names of the manager, alternate manager and delegating nurse
   • every owner of more than 25 percent and every investor holding 2 percent or more, directly or indirectly
   • disclosures about past licenses, Medicare/Medicaid-related convictions, and felony convictions.⁠³

   Attach:

   • proof of control of the building
   • any common ownership community approvals
   • a business plan and one-year operating budget
   • a letter of good standing from the Maryland Department of Assessments and Taxation (SDAT)
   • the Alzheimer’s Special Care Unit disclosure form, if you will have a unit.⁠³

   The rule also requires the Uniform Disclosure Statement, proof that the applicant is at least 21, and policies and procedures.⁠¹

2. Step two: additional documents. Once OHCQ sends instructions, submit:

   • the site plan or sketch
   • the use and occupancy permit or zoning approval
   • the fire inspection report (or the Baltimore environmental report)
   • the food service permit, at 17 or more beds
   • the Uniform Disclosure Statement
   • your resident agreement (OHCQ posts a sample template)
   • your workers’ compensation declaration page, or a Certificate of Compliance or Letter of Exemption if you are not required to carry coverage.⁠³

3. Step three: on-site survey. OHCQ schedules a survey that includes a building tour, staff interviews and a records review. The surveyor checks:

   • background checks for the owner, applicant, manager, alternate, staff and any household members
   • the manager’s and alternate’s qualifications
   • the delegating nurse’s credentials and contract
   • a 4-week menu cycle signed off as nutritionally adequate by a licensed dietitian or nutritionist
   • twelve written policies: bed and room assignment, change in accommodation, transfer, discharge, resident termination requests, documentation, complaints and grievances, adult medical day care, abuse, neglect and financial exploitation, smoking, the emergency and disaster plan, and the quality assurance plan.⁠³

Your quality assurance plan must include an annual tuberculosis risk assessment.⁠¹ If the survey finds no deficiencies, you receive a Notice of Compliance and your license. If it finds deficiencies, you get a Statement of Deficiencies and have 10 business days to submit a plan of correction. The license is issued once OHCQ accepts the plan.⁠³

OHCQ’s options under the rule are:

• approve the application unconditionally
• approve it on conditions, which can include requiring a management firm it approves for up to 24 months
• deny it.⁠¹

If you are not fully compliant but the problems are not a health or safety hazard and your plan of correction is acceptable, OHCQ can issue a provisional license for less than one year.⁠¹ An incomplete application can be closed after 180 days from first receipt, and you would then have to start over.⁠¹⁠³ You may not operate until you hold a provisional or full license.⁠¹

OHCQ can deny an application based on the owner’s, manager’s or alternate manager’s history. That includes violations of the assisted living rules, harmful criminal history, convictions described in 42 U.S.C. 1320a-7(a) or Criminal Law Article § 14-101, and final actions by a health occupations board.⁠¹ When it weighs a conviction, OHCQ considers age at the time of the crime, the circumstances, the time since, and work history after it.⁠¹ Anyone who was an owner, manager, alternate or board member of a program whose license was suspended or revoked is barred from owning or running another one for 10 years unless they show good cause.⁠¹

No application fee: the April 2026 OHCQ form says “There is no fee to apply for a license.”⁠³ The manager’s Board license fees are separate.⁠⁹

Getting paid through Medicaid

Maryland Medicaid pays for assisted living services through the Home and Community-Based Options Waiver in COMAR 10.09.54. To take part, a provider must be licensed under COMAR 10.07.14.⁠¹¹ The waiver adds conditions on top of OHCQ licensure:⁠¹¹

• Manager. The manager must be a physician, a registered nurse, a licensed practical nurse, or someone with at least 3 years of direct patient care experience. The alternate must meet the same standard.
• Daytime staffing. At least one staff person must be on duty for every eight residents during daytime hours. This is stricter than the licensing rule, which sets no ratio.
• Billing training. You must take part in the Department’s billing training.
• Case manager visits. You must allow case managers to visit at least quarterly.
• Reporting changes. You must tell a participant’s case manager within 1 working day of any significant change.

The maximum rates published in COMAR 10.09.54.22 for dates of service from July 1, 2024 are:⁠¹¹

• Level II: $90.74 a day, or $68.09 for a resident who also attends medical day care
• Level III: $114.51 a day, or $85.86 with medical day care

The rate table has no Level I line. A provider is paid the lower of its customary charge to the public and the published rate, and rates may change with the State budget.⁠¹¹ If you plan to add day services, note that an assisted living program may not provide day, partial-day or hourly adult day care without adult medical day care licensure.⁠¹ That license is covered in the Maryland adult medical day care center guide. An owner who also owns a medical day care center must disclose that to residents before referring them there.⁠¹

After licensing: surveys and changes

OHCQ surveys each program on site at least once a year. The statute requires at least one unannounced inspection a year.⁠¹⁠⁷ OHCQ can stretch the gap to 18 months if you have no open plan of correction, pending complaint, settlement agreement, unpaid civil money penalty or sanction.⁠¹ OHCQ may hand parts of this monitoring to the Department of Aging or a local health department.⁠¹ You must post your license in a common area.⁠¹ You must also post your latest statement of deficiencies, complaint investigations and plans of correction, or a notice saying where they are kept.⁠⁷

Changes that need OHCQ’s action:⁠¹⁠³⁠⁴

• More or fewer beds, or a higher level of care. You need OHCQ’s approval and a new license. OHCQ posts request forms for bed increases, bed decreases and level of care increases.
• A new manager, alternate manager or delegating nurse. Report these on OHCQ’s forms.
• Changes in services. File an amended Uniform Disclosure Statement within 30 calendar days. A copy must go out with your marketing materials.
• Relocation, or a sale, transfer or lease that changes who controls the program. Notify OHCQ and residents in writing 60 calendar days ahead if you have 49 or fewer beds, or 75 days ahead at 50 or more. The new owner or new location needs its own initial license before operating. OHCQ’s application tells new owners to file a complete application at least 45 days before the transfer.
• Code violations. Send OHCQ any building, sanitary or fire code citation within 7 calendar days of receiving it.

License term, lapses and closing

The OHCQ application form, the OHCQ provider pages and COMAR 10.07.14 reviewed on 2026-10-12 state no license expiration date, renewal cycle or renewal fee for assisted living programs. Ask OHCQ’s Assisted Living Team, (410) 402-8217, how and when your license is renewed or re-validated and whether any fee applies before you build that into a budget.⁠¹⁠²⁠³ The rule does set conditions that keep a license valid or end it:⁠¹

• The license is tied to you and the address. It is valid only in the licensee’s name and for the premises on the license, and it cannot be sold, assigned or transferred. You must tell OHCQ immediately of any change in the information in your latest application.
• Stay in good standing with SDAT. If you do not return to good standing within 60 calendar days after SDAT or another government agency notifies you, OHCQ may void the license.
• Stopping services voids the license. A license is void if the program provides no services to residents for 180 consecutive days.
• Closing voluntarily. Notify OHCQ at least 60 calendar days ahead if you are licensed for 49 or fewer beds, or 75 days ahead for 50 or more. The notice must explain how residents will be told and helped to find comparable housing. You must also notify residents in writing on the same schedule, send OHCQ weekly updates on how many residents remain and how many have relocation plans, and stop using the license once you close.
• No surrender under investigation. Unless OHCQ agrees, you cannot surrender the license, or let it lapse, while an investigation or charges are pending.

Sources

1. 1
   Maryland Division of State Documents, COMAR 10.07.14, Assisted Living Programs (revised effective April 28, 2025) Checked 12 Oct 2026 · Back to text ↑
2. 2
   Maryland Department of Health, Office of Health Care Quality, Assisted Living Programs Checked 12 Oct 2026 · Back to text ↑
3. 3
   Maryland Department of Health, Office of Health Care Quality, Application for Assisted Living Program License (April 13, 2026) Checked 12 Oct 2026 · Back to text ↑
4. 4
   Maryland Department of Health, Office of Health Care Quality, Assisted Living Programs: Provider Information, Licensure Checked 12 Oct 2026 · Back to text ↑
5. 5
   Maryland General Assembly, Health-General Article § 19-1809 (operating without a license) Checked 12 Oct 2026 · Back to text ↑
6. 6
   Maryland General Assembly, Health-General Article § 19-1807 (manager training course) Checked 12 Oct 2026 · Back to text ↑
7. 7
   Maryland General Assembly, Health-General Article § 19-1805 (regulations; inspections) Checked 12 Oct 2026 · Back to text ↑
8. 8
   Maryland General Assembly, Health-General Article § 19-311 (approval to build or alter) Checked 12 Oct 2026 · Back to text ↑
9. 9
   Maryland Department of Health, Board of Long-Term Care Administrators, Assisted Living Managers Checked 12 Oct 2026 · Back to text ↑
10. 10
    Maryland Division of State Documents, COMAR 10.33.03.03, Assisted living manager licensure, Applicant II Checked 12 Oct 2026 · Back to text ↑
11. 11
    Maryland Division of State Documents, COMAR 10.09.54, Home and Community-Based Options Waiver Checked 12 Oct 2026 · Back to text ↑

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