Last updated 2026-07-25
TL;DR
Maryland assisted living facilities need a license from the Office of Health Care Quality (OHCQ), which covers zoning approval, a completed application, background checks, a fire/life safety inspection, and level-of-care compliance under COMAR 10.07.14. Expect several months from application to opening, and budget for a licensing fee, sprinkler and life-safety upgrades, and staffing that meets Maryland's RN-delegation rules.
What is assisted living?
Assisted living is a residential care setting for adults who need help with daily activities like bathing, dressing, medication management, and meals, but don't need the round-the-clock skilled nursing care a hospital or nursing home provides. Residents typically have their own room or apartment, share common spaces, and get support from staff on a schedule built around their needs. In Maryland, the term has a specific legal meaning. State law defines an assisted living program as "a residential or facility-based program that provides housing and food service and assists with activities of daily living, instrumental activities of daily living, or health-related services for a fee" to three or more adults [1]. That definition, found in the Health-General Article of the Maryland Code, is what triggers licensing. If you're housing and caring for adults for a fee, whether it's three people in a converted single-family home or eighty people in a purpose-built building, you're running an assisted living program under Maryland law and you need a license from the Office of Health Care Quality (OHCQ).
What is an assisted living facility, exactly, under Maryland law?
An assisted living facility (sometimes called an ALP, for assisted living program, in Maryland's own paperwork) is the physical building or unit where that licensed care happens. Maryland regulates these under COMAR 10.07.14, the Assisted Living Programs regulation set administered by OHCQ, available through the Maryland Division of State Documents' online COMAR portal [2]. Maryland sorts facilities by resident level of care, more than size. The state uses three levels: Level 1 (low), Level 2 (moderate), and Level 3 (high), based on how much hands-on assistance and health monitoring a resident needs [2]. A facility's license specifies which levels it's approved to serve, and that matters because it drives your staffing ratios, your admission criteria, and whether you can keep a resident whose needs have increased. A small Level 1 home in a residential neighborhood looks very different, on paper and in practice, from a Level 3 facility that's essentially caring for people who'd otherwise be in a nursing home.
What is a group home, and how is it different from assisted living?
"Group home" is a broader, less legally precise term than "assisted living facility." People use it to describe small residential settings serving people with intellectual and developmental disabilities (IDD), mental illness, substance use recovery needs, or, sometimes, seniors. In Maryland, group homes for people with developmental disabilities are licensed separately, through the Developmental Disabilities Administration (DDA) under COMAR Title 10.22, and group homes for behavioral health populations go through the Behavioral Health Administration, not OHCQ's assisted living program [3]. If your target population is primarily seniors needing help with daily living and health monitoring, you're in assisted living licensing territory (OHCQ, COMAR 10.07.14). If you're serving adults with IDD or a primary mental health diagnosis as the basis for placement, you'll likely need a different license entirely, and mixing populations without the right license is a common and expensive mistake. Confirm with your state licensing agency which category your intended population and services fall under before you sign a lease or take a deposit from a resident. For background on how these categories differ nationally, see our guide on assisted living facilities.
What does assisted living provide, day to day?
A Maryland-licensed assisted living program has to provide housing, meals, and assistance with activities of daily living (ADLs) such as bathing, dressing, toileting, transferring, and eating, plus instrumental activities like medication reminders, housekeeping, and transportation coordination [1][2]. Facilities must also provide 24-hour supervision appropriate to the resident's assessed level of care. Health-related services are where Maryland gets specific and where new operators trip up. COMAR 10.07.14 requires an RN to complete a pre-admission assessment for every resident, establish a plan of service, and delegate nursing tasks to unlicensed staff under Maryland's Nurse Practice Act delegation rules [2][4]. That RN doesn't need to live on-site, but the facility has to have a documented relationship with one, whether an employee or contracted delegating nurse, before it admits a single resident. Skipping this step, or treating it as a formality, is one of the fastest ways to get a deficiency citation in your first survey.
What is assisted living vs nursing home, and why the license is different
| Licensing body | OHCQ, COMAR 10.07.14 [2] | OHCQ + federal CMS certification [5] | |
|---|---|---|---|
| Staffing | RN delegation model, direct care staff | 24/7 licensed nursing staff required | |
| Medicare coverage | Not covered as a facility benefit | Covered for limited skilled stays post-hospitalization | |
| Typical resident | Needs ADL help, stable medically | Needs daily skilled nursing or rehab | |
| Setting | Home-like, private or shared rooms | Clinical, hospital-adjacent feel | The practical upshot for someone opening a facility: if your business plan assumes you'll bill Medicare for room and board or basic care, that plan is wrong, and you need to fix it before you write a pro forma. |
Assisted living and nursing homes both provide residential long-term care, but they sit at different points on the acuity spectrum and answer to different regulatory frameworks. Nursing homes (skilled nursing facilities) in Maryland are licensed separately from assisted living programs and are subject to federal Medicare/Medicaid Conditions of Participation under 42 CFR Part 483, because most nursing home residents' care is paid through those programs [5]. Assisted living in Maryland is a state-only licensing category; it isn't a Medicare or Medicaid provider type at the facility level in the same way. | Feature | Assisted living (Maryland) | Nursing home |
Does Medicare cover assisted living facilities?
No. Medicare does not cover the cost of room, board, or personal care in an assisted living facility. CMS is explicit on this: Medicare Part A and Part B do not pay for long-term custodial care, which is what assisted living primarily provides [6]. Medicare may cover short-term skilled nursing or therapy services delivered inside an assisted living building (through a home health agency, for example), but it will not pay the facility's monthly rate. Medicaid is a different story, and it's worth understanding before you set your rate structure. Maryland's Medicaid program offers a Community First Choice and Community Options waiver structure that can help cover some assisted living costs for financially and medically eligible residents, but it does not pay full market rate in most cases, has limited slots, and comes with its own provider enrollment process through the Maryland Department of Health [7]. If you're planning to accept Medicaid waiver residents, budget for a separate application and slower payment cycles, and don't count on waiver revenue to cash-flow your first year.
How do I start a group home or assisted living facility in Maryland, step by step?
Here's the realistic sequence, based on OHCQ's own licensing framework [2][8]: 1. Confirm your population and license type with OHCQ (assisted living) or the relevant agency (DDA, BHA) if you're serving IDD or behavioral health populations, not seniors needing ADL support. 2. Secure a site and get zoning clearance. Maryland counties and municipalities regulate assisted living as a land use separately from state licensing, and a state license won't override a local zoning denial. Check with your local planning and zoning office before signing a lease. 3. Complete OHCQ's assisted living program license application, which includes facility floor plans, fire and life safety documentation, policies and procedures, staffing plans, and disclosure of ownership [8]. 4. Pass a fire safety inspection coordinated with your local fire marshal and, for larger facilities, the State Fire Marshal's office; sprinkler and egress requirements scale with resident count and level of care. 5. Arrange your RN delegation relationship and finalize admission/assessment policies under COMAR 10.07.14 [2][4]. 6. Pay the licensing fee (confirm the current fee schedule with OHCQ directly, since fees are set by regulation and can change). 7. Undergo a pre-licensure survey. An OHCQ surveyor visits to confirm the physical plant, policies, and staffing match what's on paper. 8. Receive your license, which specifies your approved capacity and level(s) of care. Expect this whole process to take several months at minimum, longer if construction or major renovation is involved. Rushing the zoning and fire safety steps is the number one cause of six-month delays we see operators run into.
What zoning and building rules apply before you can even apply?
Zoning is a local matter in Maryland, handled by county or municipal planning departments, not OHCQ. Many jurisdictions treat small assisted living homes (often under 8-16 residents, depending on the county) as a permitted or conditional residential use, while larger facilities may need a special exception or site plan review. Some counties also cap group residential uses by density within a given neighborhood. Building and fire code compliance is separate from zoning and separate from OHCQ licensing, but all three have to line up. Maryland generally applies the Maryland Building Rehabilitation Code and NFPA-based life safety standards through the State Fire Marshal and local fire authorities, with sprinkler and alarm requirements that get stricter as resident count and mobility/cognitive impairment levels rise. A single-family home converted for six residents faces different requirements than a new 40-bed building. Confirm with your local zoning and fire authorities early, because retrofitting a building for sprinklers or egress width after you've already signed a lease is one of the most expensive corrections an operator can make. For a broader look at how location decisions affect licensing timelines, see assisted living facility and assisted living at home for smaller-scale models.
What staffing does Maryland require?
COMAR 10.07.14 requires assisted living programs to maintain staffing sufficient for residents' assessed needs at all times, with specifics tied to the facility's approved level(s) of care [2]. A few non-negotiables show up in every OHCQ review: An RN must complete each resident's pre-admission health assessment and establish or approve the plan of service before or at admission. That RN also oversees delegation of nursing tasks (like medication administration) to unlicensed direct care staff, consistent with the Maryland Board of Nursing's delegation regulations [4]. Direct care staff need documented training specific to Maryland's assisted living curriculum requirements, covering topics like resident rights, infection control, dementia care (if you serve residents with cognitive impairment), and emergency procedures, before they work unsupervised. A facility manager or administrator, sometimes required to hold specific Maryland certification depending on facility size and level of care, needs to be designated and on file with OHCQ. Staffing ratios themselves aren't a single fixed number across the state; they scale with your licensed capacity and the acuity mix of residents you're actually serving, and OHCQ surveyors will check your ratios against your resident roster's actual care needs, more than your paper policy. Confirm current curriculum hours and administrator certification requirements directly with OHCQ, since these are updated periodically.
What does the application package actually need to include?
OHCQ's application isn't a one-page form. Plan on assembling, at minimum: a completed license application with ownership disclosure, floor plans showing resident rooms and common areas, evidence of zoning compliance, fire marshal approval or a plan for it, written policies and procedures covering admission and discharge criteria, medication management, emergency preparedness, resident rights, abuse/neglect reporting, and infection control, a staffing plan matched to your intended level(s) of care, criminal background check results for owners, administrators, and staff (Maryland requires background screening for direct care workers), and proof of liability insurance [2][8]. Most first-time applicants underestimate the policy manual. It's not enough to have a template; OHCQ surveyors check whether your actual practice matches what's written, starting on day one. This is exactly the gap our $299 State Group Home Licensing Kit is built to close: state-specific policy templates, staffing plan worksheets, and an application checklist built around what OHCQ (and other state agencies) actually ask for, so you're not reverse-engineering the requirements from scratch. You can start building your package at /licensing-kit-builder.
What happens at the inspection, and what happens after you're licensed?
Before OHCQ issues your initial license, a surveyor visits the physical site to confirm it matches your application: room sizes, exits, bathroom accessibility, kitchen and food safety setup, medication storage, and posted resident rights notices. They'll also review a sample of your policies and, once you have any residents, actual resident records and assessments. Licensing doesn't end at opening day. Maryland assisted living programs are subject to periodic unannounced surveys, and OHCQ also investigates complaints. Deficiencies get documented on a statement of deficiencies, and facilities must submit a plan of correction with target dates. Repeated or serious violations can lead to conditional licensure, fines, or, in the worst cases, license revocation. Build your first-year budget assuming at least one full survey and treat your policy manual as a living document, not a one-time compliance exercise. For operators comparing Maryland's approach to nearby states, our assisted living facilities hub has state-by-state breakdowns.
What does it typically cost and how long does licensing take?
Maryland doesn't publish one flat startup cost because it depends entirely on whether you're converting an existing home, building new, or leasing a commercial space, and how many residents and what level of care you're licensing for. Real cost drivers include the OHCQ license fee itself (confirm the current fee schedule with OHCQ, since it's set by regulation and periodically updated), fire and life safety upgrades (sprinklers alone can run tens of thousands of dollars in an older building), RN consulting or employment costs for the delegation relationship, staff training and background check costs, and liability insurance. On timeline: expect a minimum of a few months from a complete, clean application to licensure if no construction is needed, and six months to well over a year if you're renovating or building. The single biggest lever you control is submitting a complete, accurate application the first time; incomplete applications go to the back of the queue while OHCQ waits for missing documents, and that alone can add months.
Frequently asked questions
What is assisted living?
Assisted living is residential care for adults who need help with daily activities like bathing, dressing, and medication management but don't need full-time skilled nursing. In Maryland, it's a licensed category under COMAR 10.07.14, overseen by the Office of Health Care Quality, covering housing, meals, and health-related services for a fee.
What is a group home?
A group home is a residential setting where a small number of people, often with disabilities, mental illness, or substance use recovery needs, live together with support staff. In Maryland, group homes for these populations are typically licensed separately from assisted living, through agencies like the Developmental Disabilities Administration or Behavioral Health Administration.
What is an assisted living facility?
An assisted living facility is the licensed building or program providing housing, meals, and ADL assistance to three or more adults for a fee, as defined under Maryland's Health-General Article. Maryland categorizes facilities by resident level of care (Level 1, 2, or 3) based on the intensity of assistance and health monitoring needed.
What is assisted living facility care like on a daily basis?
Residents get help with bathing, dressing, toileting, and mobility as needed, plus prepared meals, medication reminders or administration under RN delegation, housekeeping, and 24-hour supervision matched to their assessed care level. Social activities and transportation coordination are common but not always state-mandated in Maryland's regulations.
What is assisted living vs nursing home?
Assisted living serves people who need help with daily activities but are medically stable; nursing homes serve people who need daily skilled nursing or rehabilitation care. In Maryland, they're licensed under different frameworks, and nursing homes must also meet federal Medicare/Medicaid Conditions of Participation that assisted living facilities do not.
What does assisted living provide that a nursing home doesn't?
Assisted living typically offers a more home-like, less clinical environment with private or semi-private rooms, more resident independence, and a focus on ADL support rather than intensive medical treatment. Nursing homes provide round-the-clock licensed nursing care, IV therapy, and rehabilitation services that most assisted living facilities aren't staffed or licensed to deliver.
How do I start a group home in Maryland?
Confirm the correct license type for your population (assisted living, IDD, or behavioral health), secure a zoning-compliant site, complete the relevant state application with floor plans and staffing plans, pass fire safety and licensing inspections, and finalize policies before admitting residents. The process typically takes several months at minimum.
How do I start an assisted living facility specifically, versus other group home types?
You'll apply to Maryland's Office of Health Care Quality under COMAR 10.07.14, which requires an RN-led admission assessment process, level-of-care-based staffing, zoning clearance, and a fire/life safety inspection. This differs from IDD or behavioral health group homes, which route through different state agencies with different rules.
Does Medicare cover assisted living facilities in Maryland or anywhere else?
No. Medicare does not cover room, board, or personal care costs in assisted living facilities anywhere in the country; it only covers limited skilled nursing or therapy services, and only under specific conditions. Families typically pay privately or, if eligible, use Medicaid waiver programs to offset some costs.
Does Maryland Medicaid pay for assisted living?
Maryland Medicaid offers waiver programs, including options under the Community Options and Community First Choice structure, that can help cover some assisted living costs for financially and medically eligible residents, but they don't cover full market rate in most cases and have limited enrollment slots. Facilities that want to accept waiver residents need separate Medicaid provider enrollment through the Maryland Department of Health.
What license do I need to open an assisted living facility in Maryland?
You need an assisted living program license from Maryland's Office of Health Care Quality (OHCQ), issued under COMAR 10.07.14. The license specifies your approved resident capacity and the level(s) of care (1, 2, or 3) your facility is authorized to provide.
How long does it take to get an assisted living license in Maryland?
For an existing, code-compliant building with a complete application, expect a minimum of a few months. If construction, major renovation, or fire safety retrofits are needed, six months to over a year is realistic. Incomplete applications add significant delay, since OHCQ pauses review until missing items arrive.
Do I need an RN on staff to run an assisted living facility in Maryland?
You need a documented RN delegation relationship, though the RN doesn't have to be a full-time on-site employee. The RN must complete pre-admission assessments, establish plans of service, and delegate nursing tasks to unlicensed staff under Maryland Board of Nursing delegation rules before you can admit residents.
Sources
- Maryland General Assembly, Health-General Article: Maryland's statutory definition of an assisted living program
- Code of Maryland Regulations, COMAR 10.07.14 (Assisted Living Programs): Assisted living licensing regulations, level-of-care system, RN assessment and delegation requirements
- Code of Maryland Regulations, Title 10.22 (Developmental Disabilities Administration licensing): DDA licenses group homes for people with developmental disabilities separately from assisted living
- Code of Maryland Regulations, COMAR 10.27.11 (Delegation of Nursing Functions): RN delegation of nursing tasks to unlicensed assistive personnel in Maryland
- Code of Federal Regulations, 42 CFR Part 483: Federal Conditions of Participation for nursing homes distinct from assisted living licensing
- CMS/Medicare.gov, Long-Term Care coverage information: Medicare does not cover long-term custodial care such as assisted living room and board
- Maryland Department of Health, Home and Community-Based Services Waivers, 1915(c) authority: Maryland Medicaid home and community-based waiver coverage limits for assisted living-type services
- Health-General Article, Title 19, Subtitle 18 (Assisted Living Programs, licensure provisions): Statutory basis for OHCQ's assisted living licensing application and survey process