Understanding Requirements for New Assisted Living Residences (ALRs) in Massachusetts
This document outlines the essential steps and ongoing obligations for establishing and operating a new Assisted Living Residence (ALR) in Massachusetts, as regulated by the Executive Office of Elder Affairs (AGE).
Key Takeaways for Your Client:
- Certification is Mandatory: You cannot operate, advertise, or even maintain a new ALR without certification from the AGE.
- Thorough Application Process: The application is comprehensive and requires detailed information about the ownership, the facility’s physical design, and operational plans, including specific staffing details.
- Compliance is Continuous: Meeting initial certification requirements is just the beginning; ongoing compliance with regulations is crucial to avoid penalties.
- Resident Rights are Protected: Massachusetts law provides specific protections for ALR residents, including those related to residency agreements and termination.
I. Getting Started: The Certification Process for New ALRs
Before you can open your doors, your new ALR must be certified by the Executive Office of Elder Affairs (AGE).
- No Operation Without Certification: It is illegal to advertise, operate, or maintain an ALR without AGE certification.
- Advertising Before Certification (Limited): You can advertise an uncertified ALR only if:
- You have formally started the application process by notifying AGE.
- All advertising clearly states that the ALR is not yet AGE-certified.
- Property Rights: You must have sufficient ownership or lease rights to the property to operate the ALR, as deemed necessary by the Secretary or his or her designee.
II. The Application for Certification for a New ALR
This is the core step to becoming a certified ALR. Be prepared for a detailed and structured submission.
- Submission Method (Effective May 2023): All applications and attachments must be submitted electronically via email to
ALRHelp@mass.gov. The subject line of the email should include the ALR name and reference the requested certification on page 1 of the application. If there are many attachments, include an index of documents. - Notarization: The application must be notarized and signed under the pains and penalties of perjury by the Applicant.
- Timing: The Application must be submitted to AGE at least 60 days prior to the date the Applicant plans to start operation of the ALR.
- Fees: AGE will charge a non-refundable fee set by the Secretary of Administration and Finance for the filing of the Application for Certification of an Assisted Living Residence. The Applicant must file a separate Application for each Assisted Living Residence for which Certification is sought.
A. What to Include in Your Application:
Your application package must contain extensive information to demonstrate your readiness and compliance.
- Ownership and Management Details:
- The name and address of each officer, director, trustee, owner, general partner, limited partner, and shareholder with a 25% or greater interest in the ALR.
- Proof of No Violations: Provide proof that none of such individuals has ever been found in violation of any local, state or federal statute, regulation, ordinance, or other law by reason of that individual’s relationship to an Assisted Living Residence or health care facility.
- Prior Healthcare/Housing Affiliations: A list for each such individual of all multi-family housing or health care facilities or providers in which she or he has been or is an officer, director, trustee, or general partner.
- Past Compliance Records (if applicable): If the Applicant or any person named in the Application has or has had, within the previous 5 years, an interest in certain healthcare entities (hospitals, clinics, long-term care facilities, etc.), evidence from the Massachusetts Department of Public Health (DPH) that the entities have substantially met applicable criteria for licensure or Certification and, if applicable, have corrected all cited deficiencies without de-licensure or de-certification being imposed. This includes:
- Hospital, clinic, long-term care facility, mammography facility, institutions for unwed mothers, out of hospital dialysis unit, hospice program, bacteriological laboratory, blood bank, or other entity licensed by the DPH under M.G.L. c. 111.
- Medical provider licensed under other applicable state statutes; including a facility, halfway house or treatment program unit for alcoholism licensed under M.G.L. c. 111B, ambulance service licensed under M.G.L. c. 111C, clinical laboratory licensed under M.G.L. c. 111D, and drug rehabilitation facility licensed under M.G.L. c. 111E.
- Home health agency in Massachusetts certified under Title XVIII of the Social Security Act.
- Conversion Approval (if applicable): A copy of the conversion approval from the DPH, if an Applicant seeks to convert all or part of a premises licensed as a Long Term Care Facility to an Assisted Living Residence or if an Applicant seeks to add Assisted Living Residences to existing premises licensed as a Long-term Care Facility.
- Comprehensive Operating Plan: This is a critical component detailing how your ALR will function. It must include:
- Unit Configuration: The number of single and double occupancy Units for which Certification is sought, the number of single and double occupancy Units designated as Special Care Units, and the number of Residents per Unit.
- Facility Layout: The location of Units and Special Care Units, common spaces, and egresses by floor.
- Fee Structure: The fee structure for lodging, meals and services.
- Services Offered: The type and extent of services to be offered, arrangements for providing such services, including third party contracts, and linkages with hospital and nursing facilities.
- Medication Management: A Plan for Self-administered Medication Management (SAMM) for Residents, including but not limited to, assistance with as-necessary medication (PRN) when part of the SAMM, and, if offered, Limited Medication Administration.
- Emergency Communication: A means for Residents to communicate urgent or emergency needs, and a plan to provide timely assistance to them.
- Staffing: The number of staff to be employed in the operation of the Assisted Living Residence and their minimum qualifications and responsibilities.
- Residency Agreement: A copy of the Residency Agreement that will be used by the Assisted Living Residence. It must clearly describe the rights and responsibilities of the Resident and Sponsor, and comply with all requirements of M.G.L. c. 19D and 651 CMR 12.00.
- Building & Safety Certificates: A copy of all required current building, fire safety, and locally approved state sanitary code certificates and permits.
- Resident Discharge Procedures: Procedures to notify a Resident and his or her Legal or Resident Representative, as appropriate, that the Assisted Living Residence is no longer an appropriate environment for the Resident. Such notice shall describe the changes in the Resident’s service needs that justify such a finding, explain when those changes occurred, and describe how the Resident’s needs can no longer be satisfied.
- Special Care Residence Policies: A copy of all policies and procedures related to the design and operation of a Special Care Residence or Residences.
- Quality Improvement Program: A copy of the quality improvement and assurance program.
- Disaster/Emergency Plan: A copy of the disaster and emergency preparedness plan.
- Communicable Disease Control Plan: A copy of the communicable disease control plan.
- Controlled Substances Policies: A copy of the Controlled Substances policies and procedures.
- Fiscal Year Dates: A statement citing the beginning and ending dates of the Residence’s fiscal year.
- Safe Environment Policies: Policies and procedures designed to ensure a safe environment for all Residents.
B. Specific Facility Requirements (from 651 CMR 12.00, Section 12.04: General Requirements)
The physical structure and design of your ALR are subject to specific regulations to ensure resident safety, privacy, and quality of life.
- Unit Requirements:
- An Assisted Living Residence shall provide only single or double Units with lockable doors on the entry door of each Unit.
- Residents shall have exclusive rights to their Units, meaning they have control over who enters and when (subject to reasonable exceptions for emergencies, maintenance, etc.).
- Bathrooms:
- Newly Constructed ALRs (building permit issued on or after June 1, 1995) must provide a private bathroom for each Unit, equipped with one lavatory, one toilet, and one bathtub or shower stall.
- All other ALRs (existing or renovated) must provide, at a minimum, a private half-bathroom (equipped with one washstand and one toilet) for each living Unit and shall provide at least one Bathing Facility for every three Residents.
- Cooking Capacity: All ALRs must provide, at a minimum, either a kitchenette or access to a refrigerator, sink, and heating element for all Residents. However, as part of a Resident’s Service Plan, such access may be limited to supervised access if clinically appropriate.
- Common Spaces and Environment:
- The ALR must provide a safe, comfortable, and therapeutic environment that promotes the physical, social, and emotional well-being of its Residents.
- There must be adequate common spaces for dining, social activities, and recreation suitable for the number and needs of residents.
- Accessibility: The facility must be accessible to individuals with disabilities, complying with all applicable federal and state accessibility standards.
- Egresses: Clearly marked and accessible egresses (exits) must be provided on each floor. Your operating plan requires detailed location of these.
- Fire Safety: The facility must comply with all applicable state and local fire safety codes, and current fire safety certificates and permits must be submitted.
- Sanitary Code: The facility must comply with all applicable state sanitary codes, and locally approved certificates and permits must be submitted.
- Special Care Residence/Units (if applicable):
- If the ALR intends to provide “Special Care” for Residents (e.g., for cognitive impairments like dementia), specific additional requirements apply to these areas:
- Secured Doors: Entry and exit doors in common use areas within Special Care Residences must be secured in accordance with local, state, and federal laws and regulations. Crucially, all doors must automatically unlock in the case of fire, power outage, or emergency situation.
- Multipurpose Activity Space: A Special Care Residence must provide a multipurpose activity space.
- Structured Activities: A planned activity program must include structured activities with designated staff a minimum of three times within a 24-hour period, seven days per week, addressing various areas of Resident function.
- Environmental Safety: Policies and procedures must be developed and implemented to assess and reduce the risk of potential hazards in the physical environment related to the special characteristics of the population (e.g., wandering risks).
- If the ALR intends to provide “Special Care” for Residents (e.g., for cognitive impairments like dementia), specific additional requirements apply to these areas:
C. Specific Staff Requirements (from 651 CMR 12.00, Section 12.05: General Requirements)
Your operating plan’s staffing section must align with these detailed requirements.
- Administrator:
- Each ALR must have a qualified Administrator who is responsible for the overall management of the Residence.
- Qualifications: The Administrator must be at least 21 years of age and possess:
- A bachelor’s degree and two years of experience in a management or supervisory capacity in a health care facility or other related experience; or
- Three years of experience in a management or supervisory capacity in a health care facility or other related experience.
- The Administrator must not be actively serving as an Administrator for more than one ALR unless the Secretary or his or her designee approves a waiver.
- Registered Nurse (RN):
- The ALR must employ or contract with a Registered Nurse (RN) who shall be responsible for the coordination of all personal care services provided to Residents.
- Responsibilities: The RN must review and approve the Resident’s service plan, assess Resident needs, and coordinate services.
- The RN must be licensed to practice in Massachusetts.
- Direct Care Staff:
- The ALR must have sufficient qualified direct care staff to meet the personal care and supportive service needs of all Residents.
- Availability: Direct care staff must be available 24 hours a day.
- Training: Individuals responsible for providing personal care services must either complete personal care training prior to providing personal care services or be exempt from this requirement (as per 651 CMR 12.07(6)).
- Background Checks: All direct care staff (and any other staff having direct contact with Residents) must undergo criminal background checks (CORI checks) as required by law.
- Support Staff:
- The ALR must employ sufficient support staff for tasks such as meal preparation, housekeeping, maintenance, and administrative duties.
- These staff members must also meet any applicable qualification or training requirements for their roles.
- Staffing Levels:
- The operating plan must specify the number of staff employed in the operation and their minimum qualifications and responsibilities.
- While specific ratios are not always set in stone for general ALRs, the expectation is that staffing levels are adequate to meet the scheduled and reasonably foreseeable unscheduled Resident needs as required by the Residents’ assessments and service plans on a 24-hour per day basis.
- For Special Care Residences, it is never considered sufficient to have fewer than two staff members in the unit at all times.
III. Application Review and Evaluation
AGE will thoroughly review your application to ensure it meets all criteria.
- Pre-Approval Requirements: AGE will not approve your Application for Certification unless:
- The Application includes all information required by AGE.
- The Application includes all required attachments and statements that are required for the Certification.
- The Applicant has paid all required Application fees.
- The Secretary or his or her designee has conducted a compliance review of the Assisted Living Residence and has reasonably determined that the premises meets the requirements of M.G.L. c. 19D and is in compliance with 651 CMR 12.00.
- The Secretary or his or her designee has conducted a review of the Applicant and has reasonably determined that the Applicant meets the requirements of M.G.L. c. 19D and is in compliance with 651 CMR 12.00.
- Potential Denial: AGE may, in its discretion, deny Certification to any Applicant who has directly or indirectly had an ownership interest in certain healthcare entities with a history of serious issues (patient care receivership, de-certification, abuse/neglect, repeated serious violations).
IV. Certification Fee
Upon receiving notice of Certification, there’s a final fee.
- Payment Timeline: A Sponsor shall forward within 10 days to AGE a Certification fee, set by the Secretary for Administration and Finance pursuant to M.G.L. c. 7, § 3B based on the number of Units certified on the date of its most recent Application.
- Fee Adjustments: In the event that the Applicant or Sponsor of an Assisted Living Residence alters the Residence by the addition or removal of Units, a fee adjustment may be made by AGE.
- Non-Compliance: Failure to pay the fee within the 10 day period shall result in a finding of non-compliance by AGE under 651 CMR 12.09.
- HUD Exemption: No fee for initial certification shall be due from any Assisted Living Residence created under the HUD Assisted Living Conversion Program.
V. Designation of Units for Assisted Living
Clarifies how units within a facility are designated as ALR units.
- All Units Meet Requirements: If all units within a facility meet the physical requirements of assisted living regulations, the Residence is not required to designate the specific units for certification.
- Not All Units Meet Requirements: If units are not being used as assisted living units, and all units do not meet the physical requirements, the residence must designate the specific assisted living units for certification.
- Avoid Uncertified Units: However, it is important that the Residence not open additional units to residents above the maximum approved number without completing the certification process.
- Penalties for Uncertified Units: Any residence operating assisted living units without certification is subject to a civil penalty of up to $500 per unit/per day, plus additional monetary penalties for referring residents to uncertified units.
VI. Landlord/Tenant Law
Even though it’s an ALR, landlord/tenant laws apply, particularly regarding resident termination.
- Eviction Process: Unless a resident leaves voluntarily, assisted living residences must terminate the residency agreement in accordance with the landlord/tenant law. M.G.L. Chs. 186 and 239 are pertinent to an eviction process.
- Notice Period:
- According to the landlord/tenant law, the Residence must provide at least 14 days notice prior to termination of an agreement for non-payment of rent.
- All other termination clauses must be specified in the agreement and must state the length of notice that will be given.
VII. Personal Care Services
Rules regarding who can provide personal care.
- Staff Training: Individuals responsible for providing personal care services must either complete personal care training prior to providing personal care services or be exempt from this requirement. See 651 CMR 12.07(6).
- Private Contracts: Residences are not responsible for any personal care services contracted for privately by the resident and/or their family members if the services are not part of the service plan or if the resident contracts with a provider with no affiliation with the residence. Residences may request that the resident notify the management if any such arrangements are being made between a resident and a private provider but may not establish requirements that infringe on a resident’s right to privately contract for services.
Additional Relevant Information for Your Client (New Facilities):
- Initial Compliance Review: Be prepared for a thorough compliance review by AGE before your application is approved. This will involve an inspection of the premises to ensure it meets all physical requirements and that your operational plans are sound.
- Blueprints and Plans: While not explicitly listed as a required attachment to the application in the provided text, typically, for a new facility, architectural blueprints, floor plans, and possibly site plans will be necessary for AGE to assess compliance with physical requirements like unit size, bathroom configurations, common spaces, and egresses. Encourage your client to inquire about these specific submission needs.
- Construction and Local Permits: Beyond the AGE certification, your client will need to ensure compliance with all local zoning, building, and occupancy permits. These are critical and usually need to be in place before the AGE can certify the facility.
- Financial Viability: While not explicitly detailed as an application item, AGE will want assurance that the ALR is financially viable to provide consistent, high-quality care. This often means demonstrating adequate capital and operating funds.
- Marketing and Admissions: While initial advertising is permitted under certain conditions, ensure your client understands the ethical and legal boundaries for marketing and admissions once certified. The residency agreement is a key document in this process.
- Massachusetts Executive Office of Elder Affairs (AGE): This is the primary regulatory body. Direct your client to their official website for the most up-to-date regulations, forms, and guidance. The provided links “Assisted Living Regulations” and “Apply to certify an Assisted Living Residence” are excellent starting points.
By understanding these comprehensive requirements for the facility itself, staffing, and operations, and proactively planning for compliance, your client will be well-positioned to successfully establish and operate a certified Assisted Living Residence in Massachusetts. Sources
Navigating the complexities of ALR certification in Massachusetts can be challenging. Softiya offers expert consultation services to guide you through every step of this process. With a proven track record, we’ve successfully helped over 100 companies get their Assisted Living Residences started. Let us help you achieve your goals efficiently and compliantly.
