Last updated 2026-07-25
TL;DR
MDH is the Maryland Department of Health, the agency that licenses assisted living programs under COMAR 10.07.14. It sets three levels of care, requires a criminal background check and inspection before licensure, and regulates staffing, medication administration, and resident agreements for assisted living operators statewide.
What is MDH and why does it matter for assisted living?
MDH stands for the Maryland Department of Health. It's the state agency responsible for licensing and regulating assisted living programs in Maryland, along with nursing homes, group homes for people with developmental disabilities, and a long list of other health facilities. If you want to open an assisted living home anywhere in Maryland, MDH is the agency you'll deal with from day one. The specific rules live in COMAR 10.07.14, Maryland's assisted living program regulation, which defines what an assisted living program is, who can operate one, and what level of care each resident can receive [1]. MDH doesn't just hand out licenses and disappear. It conducts pre-licensure inspections, investigates complaints, and re-inspects licensed programs on a schedule tied to risk and history. Any Maryland resident or family member checking on a facility can also ask MDH's Office of Health Care Quality about survey results, since that office handles the inspection and enforcement side of things [2]. One thing trips people up. MDH licenses "assisted living programs," not "assisted living facilities" in the exact wording of the regulation, though the terms get used interchangeably in everyday conversation. The regulatory term matters because it defines the legal scope of what you're allowed to do under that license.
What is assisted living?
Assisted living is a residential care model for people who need help with daily activities like bathing, dressing, medication management, and meal preparation, but who don't need the round-the-clock skilled nursing care a nursing home provides. Residents typically live in private or semi-private rooms and pay for a combination of housing, meals, and personal care services. Maryland's regulation defines an assisted living program as a residential or facility-based setting that provides housing and food service along with personal care and health-related services to individuals who need those services because of physical or cognitive limitations [1]. It's meant to bridge the gap between fully independent living and a nursing facility. Most states, including Maryland, split assisted living into tiers based on how much care a resident needs. Maryland uses three levels: Level 1 (low), Level 2 (moderate), and Level 3 (high) [1]. A resident's level gets determined by an assessment, and the assigned level dictates what kind of staffing and health monitoring the program has to provide for that person. This level system is important for operators. It directly affects your staffing ratios and the training your staff need. A Level 3 resident, who might need more hands-on nursing oversight, requires a different care plan and staff competency than someone at Level 1 who mainly needs medication reminders and help with laundry.
What is a group home?
A group home is a small residential setting where a limited number of unrelated people live together and receive support services, often organized around a specific population such as adults with intellectual or developmental disabilities, people in mental health recovery, or youth in foster care systems. The term is broad and gets used across very different licensing categories depending on the state. In Maryland, group homes for people with developmental disabilities are licensed separately from assisted living, generally under the Developmental Disabilities Administration rather than through the assisted living regulation at COMAR 10.07.14. Group homes for behavioral health populations fall under yet another set of rules through the Behavioral Health Administration. This is a common point of confusion nationally. "Group home" and "assisted living" sometimes describe overlapping physical setups (a few residents, a shared house, live-in or shift staff) but they're licensed under completely different statutes with different population requirements, staffing rules, and funding streams. If you're deciding which license to pursue, the population you intend to serve determines the pathway, not the size or shape of the house. For a broader look at how group home licensing works across different states and populations, see our state-by-state licensing guides.
What is an assisted living facility?
An assisted living facility is the physical building or home where an assisted living program operates, licensed to house residents and deliver personal care, meals, and support services under state supervision. In everyday language, people use "assisted living facility" and "assisted living program" to mean the same thing, but Maryland's regulation technically licenses the program, which then operates out of a specific physical site. This distinction shows up on paperwork. When you apply to MDH, you're applying to operate a program at a named address, and that license doesn't automatically transfer if you move locations or add a second site. Each physical location generally needs its own license and its own pre-licensure inspection [1]. Assisted living facilities in Maryland range enormously in size, from small group homes with four or five residents to large multi-story buildings with over a hundred beds. The regulatory floor (background checks, staffing minimums, resident agreements, medication rules) applies regardless of size. Larger facilities often have additional requirements around administrator qualifications and building/fire code compliance tied to occupancy load.
What does assisted living provide?
| Room and board | Skilled nursing / ventilator care | |
|---|---|---|
| Help with ADLs (bathing, dressing) | Physical therapy (billed separately, often Medicare) | |
| Medication administration | Memory care add-on programs (extra fee tier) | |
| Meals and snacks | Private duty aides beyond staffing ratio | |
| Basic housekeeping/laundry | Hospice services (coordinated but separately billed) | |
| Social activities | Transportation beyond scheduled outings | The exact service list and fee structure varies by state and by individual facility. Any specific service commitment should come from the written resident agreement, not a general assumption based on what "assisted living" sounds like it should include. |
Assisted living typically provides housing, meals, help with activities of daily living (bathing, dressing, mobility, toileting), medication management or administration, housekeeping, laundry, social and recreational activities, and 24-hour staff availability for emergencies. It does not typically provide the intensive, ongoing skilled nursing care that a nursing home delivers. Under COMAR 10.07.14, Maryland assisted living programs must have a written resident agreement covering the specific services provided, the fees charged, and the conditions under which a resident could be discharged or transferred [1]. Programs must also conduct a pre-admission screening to confirm the person's needs match the level of care the program is licensed and staffed to provide. Here's a rough breakdown of what's commonly included versus what usually costs extra or isn't covered at all: | Typically included | Often extra or not covered |
What is the difference between assisted living and nursing home care?
Assisted living is for people who need help with daily activities but are largely mobile and don't require constant medical supervision. Nursing homes (also called skilled nursing facilities) are for people who need daily medical care, rehabilitation, or supervision from licensed nurses around the clock. The staffing, licensing category, and cost structure differ substantially between the two. Nursing homes are subject to federal nursing home requirements tied to Medicare and Medicaid certification, including mandated care planning rules enforced through CMS survey processes under 42 CFR Part 483, Subpart B [3]. Assisted living programs are state-licensed but are not federally certified nursing facilities, and they don't have the same nursing-coverage mandates. Cost is a real differentiator too. National cost surveys and state ombudsman data have generally shown assisted living running lower per month than a semi-private nursing home room, though exact figures shift year to year and by region. Anyone budgeting should pull current numbers from their state's aging services office rather than relying on national averages alone. The practical test operators and families use: if the person can direct their own care with help and support (assisted living), versus needs a nurse actively managing their medical condition day to day (nursing home), that's usually the dividing line.
What is assisted living vs nursing home in terms of licensing and oversight?
Assisted living programs and nursing homes are licensed under separate regulatory chapters with separate inspection cycles, staffing rules, and enforcement mechanisms, even within the same state health department. In Maryland, both fall under MDH, but assisted living is governed by COMAR 10.07.14 while nursing facilities answer to a different, more extensive set of federal Conditions of Participation [1][3]. Nursing homes that accept Medicare or Medicaid payment must also meet those federal Conditions of Participation set by CMS, and those facilities get surveyed using the federal survey process in addition to any state-specific inspection [3]. Assisted living programs generally answer only to the state licensing agency unless the state has layered in a separate Medicaid waiver oversight structure for assisted living services. This matters for anyone comparing the two license types. Assisted living licensure, while still rigorous, doesn't carry the same federal certification burden. That's part of why the personal care and staffing rules read differently between the two documents even when they're issued by the same department.
Does Medicare cover assisted living facilities?
No. Medicare does not cover the cost of room and board or personal care services in an assisted living facility. Medicare.gov explains that skilled nursing facility coverage is tied to a qualifying hospital stay and specific skilled care needs, and that custodial, long-term personal care, which is what assisted living primarily provides, sits outside that coverage entirely [4]. Medicare can still matter for an assisted living resident, just not for the housing or personal care piece. Medicare Part A and Part B can cover medically necessary services delivered to someone living in assisted living, such as physician visits, physical therapy, durable medical equipment, or a short skilled nursing stay following a qualifying hospital stay, but none of that pays for the facility's monthly rate. Medicaid is a different story and is the program most people actually mean when they ask about coverage. Some states offer Medicaid Home and Community Based Services (HCBS) waivers that help cover personal care costs in assisted living settings for financially eligible residents. Medicaid.gov describes these waivers as a mechanism states use to provide services in home and community settings as an alternative to institutional care [5]. Maryland has its own HCBS waiver programs administered through MDH. Eligibility, waitlists, and covered services should be confirmed directly with MDH's Medicaid waiver program office since these rules change and vary by state. For operators building a business plan, this distinction is not optional detail. If your pro forma assumes Medicare will pay a resident's monthly rate, that assumption is wrong and needs to come out before you take the plan to a lender or investor.
How do I start a group home or assisted living program?
Starting a group home or assisted living program generally means choosing your population and license type, confirming zoning, completing a state license application with background checks and a facility inspection, writing your policies and staffing plan, and passing a pre-licensure survey before you can accept residents. The specific steps and forms differ by state and by license category (assisted living, IDD group home, mental health group home, adult foster care). Here's the general sequence most operators follow, adjusted to your state's actual requirements: 1. Pick your license category and population. Assisted living, IDD group home, mental health residential, adult foster care, and recovery residences are usually licensed under different statutes with different staffing and training rules. Confirm with your state licensing agency which category matches the population you intend to serve. 2. Check zoning before you sign a lease. Local zoning ordinances often restrict group residential use in certain districts, and some states have separate "reasonable accommodation" processes for group homes serving people with disabilities. Confirm with your local planning department and state licensing agency before committing to a property. 3. Complete the state application. This usually includes an entity formation document (LLC or corporation), a criminal background check for owners and staff, proof of financial capacity, a fire and building safety inspection, and a facility floor plan. 4. Write your policy and procedure manual. Licensing agencies typically require written policies covering medication management, emergency procedures, resident rights, admission and discharge criteria, staffing plans, and incident reporting before they'll schedule a licensing inspection. 5. Staff and train before inspection. Most states require documented staff training (CPR, first aid, abuse reporting, medication administration if applicable) completed prior to licensure, not after residents move in. 6. Pass the pre-licensure inspection. A state surveyor visits the physical site to confirm the building, staffing, and paperwork all match what the application claims before issuing the license. 7. Get licensed, then get inspected again. Ongoing compliance means periodic re-inspections, incident reporting, and renewal applications on a cycle set by your state. Building the actual application packet and manual set from scratch is the part that eats the most time, since every state wants its own combination of forms, policy language, and staffing math. If you want a structured starting point instead of assembling it from forty different PDF templates, GroupHomePath's $299 State Group Home Licensing Kit gives you a state-specific document set to build from rather than starting with a blank page.
How do I start a group home in my specific state?
Every state has its own licensing agency, application forms, fee schedule, and inspection process for group homes and assisted living. The honest answer is: start with your state's licensing agency website and treat national guides as a framework, not a substitute. In Maryland, that means going through MDH and the Office of Health Care Quality for assisted living, or the Developmental Disabilities Administration for IDD group homes [1][2]. A few things are close to universal across states even though the specifics differ. You'll need a background check for anyone with resident contact, a written staffing plan tied to resident acuity, a facility that passes a life-safety inspection, and a policy manual covering medication handling, emergency response, and resident rights. What differs wildly is the fee amount, the required staff-to-resident ratio, the specific forms, and how long the review takes. Don't assume your state's rules mirror a neighboring state's rules just because the population served looks similar. A staffing ratio that's compliant in one state can be a citation waiting to happen in another. Confirm every number, every form name, and every fee with your state licensing agency directly before you build a budget or a timeline around it.
How does inspection and enforcement work for assisted living under MDH?
MDH's Office of Health Care Quality conducts licensing surveys, investigates complaints, and can issue deficiency citations, conditions on a license, or in serious cases, suspend or revoke a license for an assisted living program that fails to meet COMAR 10.07.14 requirements [2]. Inspections happen both before initial licensure and on a recurring basis afterward, plus in response to specific complaints from residents, families, or staff. Operators should expect surveyors to review resident records, medication administration logs, staffing schedules against required ratios, the physical building for life-safety compliance, and interviews with residents and staff. A deficiency doesn't automatically mean license revocation. Most result in a required plan of correction with a follow-up visit to confirm the fix actually happened. For a broader look at what state inspectors typically check across assisted living and group home categories nationally, see our guide on assisted living facilities licensing requirements.
What should I compare before choosing assisted living, a group home, or another care setting?
The right setting depends on the level of medical need, the specific population being served, and what the state license actually authorizes the facility to do, not on marketing language used by any individual property. Comparing options means checking the license type first, not the amenities. A few comparison questions worth asking directly of any facility or program: What license type does MDH (or your state's equivalent agency) show for this specific address? What level of care is the resident assessed at, and does the program's staffing match that level? Is Medicaid waiver funding accepted, and is there a waitlist? What's the actual written discharge policy if the resident's needs increase beyond what the program can provide? If you're researching options for a family member rather than opening a business, our guide to assisted living facilities near me covers how to search state license databases directly instead of relying on ad-driven directory sites. If you're the one building the business, our assisted living at home guide covers the smaller-scale residential model some operators start with before scaling to a larger facility.
Frequently asked questions
What is assisted living?
Assisted living is a residential care setting for people who need help with daily activities like bathing, dressing, and medication management, but don't need full-time nursing care. Residents get housing, meals, and personal care support. In Maryland, assisted living programs are licensed by MDH under COMAR 10.07.14, with three levels of care based on resident need.
What is a group home?
A group home is a small residential setting where a limited number of unrelated residents live together and receive support services, often tied to a specific population like IDD, mental health, or foster youth. It's licensed differently than assisted living in most states, including Maryland, where group homes fall under separate administrations depending on the population served.
What is an assisted living facility?
An assisted living facility is the physical location where a licensed assisted living program operates, providing housing, meals, and personal care services to residents. The license attaches to the program at a specific address, so operators generally need a separate license for each physical site under state regulations like Maryland's COMAR 10.07.14.
What does assisted living provide?
Assisted living typically provides room and board, help with daily activities like bathing and dressing, medication management, meals, housekeeping, and social activities. It does not typically provide skilled nursing care, rehabilitation therapy, or the intensive medical monitoring found in a nursing home, though some medical services can be delivered on-site by outside providers.
What is the difference between assisted living and a nursing home?
Assisted living serves people who need help with daily activities but not constant medical care. Nursing homes provide 24-hour skilled nursing care for people with more intensive medical needs, and they're subject to federal Medicare/Medicaid Conditions of Participation that assisted living programs generally aren't held to.
Does Medicare cover assisted living facilities?
No. Medicare does not pay for room, board, or custodial personal care in assisted living. Medicare.gov confirms skilled nursing facility coverage is limited to specific medical criteria after a qualifying hospital stay, not long-term custodial care. Medicare can still pay for medically necessary services like doctor visits or therapy delivered to a resident living there, but not the facility's monthly charges.
How do I start a group home?
Start by identifying which population you'll serve and which state license category applies, then confirm zoning, complete the state application with background checks, write your policy and staffing manuals, get your staff trained, and pass a pre-licensure inspection. Every state's specific forms and fees differ, so confirm details directly with your state licensing agency.
How do I start an assisted living business specifically?
Follow the same core steps as any group home: pick your license category (assisted living specifically, if that's your target population), secure a compliant property, complete the state application and background checks, build your resident agreement and level-of-care assessment process, staff appropriately, and pass your state's pre-licensure inspection before accepting residents.
What is MDH and what does it regulate?
MDH is the Maryland Department of Health. It licenses and regulates assisted living programs, nursing homes, group homes, and many other health facilities in Maryland. Assisted living specifically is governed by COMAR 10.07.14, and inspections are handled through MDH's Office of Health Care Quality.
Is assisted living the same as a nursing home?
No. They're different license types with different staffing requirements and different populations served. Assisted living is for people needing help with daily activities; nursing homes are for people needing ongoing skilled medical or nursing care. They're regulated under separate chapters of state and federal code even when the same agency licenses both.
Does Medicaid pay for assisted living?
It can, depending on the state and program. Many states, including Maryland, offer Medicaid Home and Community Based Services (HCBS) waivers that help cover personal care costs in assisted living for financially eligible residents. Coverage, waitlists, and eligibility rules vary significantly, so confirm current details directly with your state Medicaid office.
What's the difference between a group home and an assisted living facility?
Group homes and assisted living facilities can look similar physically (small residential settings with shared staff) but are usually licensed under entirely different statutes tied to different populations, such as IDD, mental health, or seniors needing personal care. The license category, not the building type, determines which rules apply.
How long does it take to get an assisted living or group home license?
Timelines vary widely by state and by how complete the application packet is when submitted. Expect the process, from application submission through pre-licensure inspection and license issuance, to take multiple months in most states. Confirm expected processing timelines directly with your state licensing agency since no single national timeline applies.
Sources
- Maryland Register / COMAR, Title 10, Subtitle 07, Chapter 14, Assisted Living Programs: Maryland assisted living programs are licensed under COMAR 10.07.14 with three levels of care and required resident agreements
- Maryland Department of Health, Office of Health Care Quality: MDH's Office of Health Care Quality conducts licensing inspections and complaint investigations for assisted living programs
- 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities: Nursing homes accepting Medicare/Medicaid must meet federal Conditions of Participation surveyed by CMS
- Medicare.gov, Skilled Nursing Facility (SNF) Care coverage: Medicare doesn't cover room and board or custodial long-term care costs
- Medicaid.gov, Home & Community Based Services 1915(c): States use HCBS waivers to provide services in home and community settings as an alternative to institutional care
- Maryland Health-General Article Section 19-1801, Assisted Living Programs Definitions: Maryland's Health-General Article defines the statutory basis for assisted living program licensure that COMAR 10.07.14 implements