Skilled Nursing Services in Maryland offer clinical care by licensed nurses to individuals with medical conditions requiring assessment, treatment, and monitoring. These services are provided through Home and Community-Based Services (HCBS) waivers such as the Community Pathways Waiver, Community First Choice (CFC), and the Community Options Waiver. Services can be delivered in homes, schools, or community settings.

1. GOVERNING AGENCIES

Agency: Maryland Department of Health (MDH)
Role: Oversees Medicaid, DDA, and CFC nursing services

Agency: Office of Health Care Quality (OHCQ)
Role: Licenses Residential Service Agencies (RSAs) providing skilled nursing in the community

Agency: Developmental Disabilities Administration (DDA)
Role: Authorizes skilled nursing for participants with complex needs under DDA Waivers

Agency: Centers for Medicare & Medicaid Services (CMS)
Role: Ensures that services meet federal HCBS and clinical care standards

2. SKILLED NURSING SERVICE OVERVIEW

Skilled Nursing Services include intermittent or continuous care provided by an RN or LPN under a medical plan of care. Services may include:

• Wound care and dressing changes
• Medication administration and injection
• Enteral (tube) feeding support
• Catheter care and bowel programs
• Tracheostomy or ventilator support
• Chronic condition monitoring (e.g., diabetes, seizures)
• Training caregivers on medical tasks
• Health assessment and reporting to physicians

All services must be part of the participant’s Person-Centered Plan (PCP) and require medical necessity authorization.

3. LICENSING & PROVIDER APPROVAL REQUIREMENTS

To provide skilled nursing in Maryland, agencies must:

• Register with the Maryland Department of Assessments and Taxation (SDAT)
• Obtain an EIN and Type 2 NPI
• Apply to be a licensed Residential Service Agency (RSA) via OHCQ
• Enroll as a Medicaid provider via ePREP
• Meet COMAR 10.07.05 standards for staffing, documentation, and supervision
• Employ or contract licensed RNs and LPNs in good standing
• Maintain clinical record systems, malpractice insurance, and emergency protocols

4. OHCQ & DDA LICENSING / ENROLLMENT PROCESS

Step 1: Business Setup

• Establish LLC or corporation, obtain EIN and NPI

Step 2: OHCQ Residential Service Agency (RSA) Application

• Submit initial license application, program description, nurse administrator resume, policy manual, sample care plans, infection control plan

Step 3: OHCQ Inspection

• Pass a site visit reviewing staff files, medical documentation, quality assurance protocols, and supervisory procedures

Step 4: Medicaid Enrollment via ePREP

• Apply under “Skilled Nursing” for DDA, CFC, or CO Waiver billing

Step 5: Receive Approvals and Begin Service Delivery

• Accept participant referrals and submit documentation through LTSS Maryland

5. REQUIRED DOCUMENTATION

• Articles of Incorporation or LLC certificate
• IRS EIN and NPI documentation
• OHCQ RSA license approval
• Medicaid enrollment confirmation

Clinical policy & procedure manual including:

• Plan of care templates and physician orders
• Medication administration record (MAR) logs
• RN and LPN delegation protocols
• Supervision and competency review logs
• Infection control and universal precautions
• Incident reporting and emergency response plans
• HIPAA compliance and protected health information protocols
• Quality assurance/improvement procedures

6. STAFFING REQUIREMENTS

Role: Registered Nurse (RN)
Requirements: Active Maryland RN license, CPR certification, experience in community nursing, supervisory training

Role: Licensed Practical Nurse (LPN)
Requirements: Active Maryland LPN license, supervised by RN, trained in delegated care tasks

Role: Nursing Administrator / Clinical Supervisor
Requirements: RN with administrative experience; responsible for oversight of care quality and staff supervision

Training Requirements:

• HIPAA and confidentiality
• Infection control and PPE
• Delegation, documentation, and incident response
• CPR/BLS certification
• Annual competency checks and continuing education

7. MEDICAID WAIVER SERVICES

Skilled Nursing is reimbursed under:

• Community Pathways Waiver (DDA) – For medically complex individuals with intellectual/developmental disabilities
• Community First Choice (CFC) – For adults meeting nursing facility level of care
• Community Options Waiver (CO) – For seniors and adults with physical disabilities
• Model Waiver for Medically Fragile Children – Pediatric in-home skilled nursing
• Increased Community Services (ICS) – For individuals transitioning from institutions

Approved services include:

• Nursing assessments and monitoring
• In-home medical procedures and training
• Short- or long-term skilled nursing support
• RN supervision of delegated nursing tasks

8. TIMELINE TO LAUNCH

Phase: Business Registration and NPI/EIN
Timeline: 1–2 weeks

Phase: RSA License Application and Policy Manual
Timeline: 4–6 weeks

Phase: OHCQ Inspection and Licensing
Timeline: 6–8 weeks

Phase: Medicaid Provider Enrollment and Start of Services
Timeline: 4–6 weeks (can overlap with licensing)

9. CONTACT INFORMATION

Maryland Office of Health Care Quality (OHCQ)
Website: https://health.maryland.gov/ohcq
Phone: (410) 402-8217
Regulations: COMAR 10.07.05

Maryland Medicaid Provider Enrollment (ePREP)
Website: https://eprep.health.maryland.gov

LTSS Maryland (for waiver documentation & billing)
Website: https://ltss.health.maryland.gov

Maryland Board of Nursing
Website: https://mbon.maryland.gov

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10. SCOPE OF WORK

• Business registration (LLC, EIN, NPI)
• OHCQ RSA license application and inspection prep
• Clinical policy & procedure manual development
• Staff credentialing trackers and nurse delegation templates
• Care plan and documentation forms
• Secure HIPAA-compliant communication system setup
• LTSS billing setup and Medicaid compliance tools
• Referral coordination with hospitals, CCS agencies, and MCOs

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