Maryland Hospice Regulations & Laws
Important Notice: This document has been thoroughly reviewed and verified against current Maryland statutes and regulations.
While Maryland regulations are updated quarterly, this document reflects the law as of July 2025.
Users should verify critical requirements with official sources before making operational decisions.
I. Maryland Hospice Statutory Framework
A. Health-General Article, Title 19, Subtitle 9: Hospice Care Facilities
1. Definitions (Health-General § 19-901)
General hospice care program
“A coordinated, interdisciplinary program of hospice care services for meeting the special physical, psychological, spiritual, and social needs of dying individuals and their families, by providing palliative and supportive medical, nursing, and other health services through home or inpatient care during the illness and bereavement:
- To individuals who have no reasonable prospect of cure as estimated by a physician; and
- To the families of those individuals.” [Source: Maryland Code § 19-901]
Limited Hospice Care Program
“A coordinated, interdisciplinary program of hospice care services for meeting the special physical, psychological, spiritual, and social needs of dying individuals and their families, by providing palliative and supportive nonskilled services through a home-based hospice care program during illness and bereavement.”
Home-based hospice care program
“A program that directly or through a contractual arrangement provides a hospice care program in the residence of the patient.”
General license
“A license issued by the Secretary to operate a general hospice care program.”
Limited license
“A license issued by the Secretary to operate a limited hospice care program.”
Verification Note: The definition of “hospice facility” was not found in current § 19-901 during July 2025 verification. This definition may appear elsewhere in the subtitle or may have been removed in recent amendments.
[Source: FindLaw verification]
2. Medication Management (Health-General § 19-914)
Scope of Application:
- Applies to general hospice care programs only when providing hospice services in an in-home setting;
- Does not apply when providing services in nursing homes, assisted living facilities, or general hospice care program facilities.
Required Policies:
- Written policy outlining procedures for collection and disposal of patients’ unused prescription medication;
- Procedure requiring discussion with patient/family at enrollment;
- A written copy of the policy must be provided to the patient and their family.
Collection and Disposal Requirements:
- Collection as soon as practicable upon:
- Death of the patient;
- Discharge from hospice care;
- Discontinuation of medication by prescriber;
- Written authorization required before collection/disposal.
- If refused, staff must urge safe disposal in accordance with EPA and DEA guidelines.
Disposal Standards:
- Must follow federal Environmental Protection Agency guidelines;
- Must follow federal Drug Enforcement Administration guidelines;
- Disposal at site where hospice care was provided;
- Documentation required.
[Source: Maryland Statutes § 19-914]
B. Certificate of Need Requirements (Health-General § 19-120)
1. Basic Requirements
When Certificate of Need is Required:
- Establishment of a home health program, hospice program, or freestanding ambulatory surgical center or facility;
- Capital expenditures exceeding statutory thresholds;
- Changes in bed capacity or service scope.
Statewide Prohibition:
- The Commission may not issue a certificate of need that authorizes a general hospice to provide home-based hospice services on a statewide basis.
2. Acquisition Restrictions
Maryland Hospice Acquisition Limitations:
- For merger with or acquisition of existing general hospice;
- Purchaser may only acquire authority to provide home-based hospice services in jurisdictions where seller is licensed;
- Written notice required thirty days before contractual arrangement;
- Commission review period of thirty days.
Jurisdictional Limitations (Health-General § 19-906):
General hospice may not be licensed to provide home-based hospice services in a jurisdiction unless:
- The hospice or acquired entity provided services in that jurisdiction during a twelve-month period ending December 31, 2001;
- Secretary specifies authorized jurisdictions in consultation with Maryland Health Care Commission.
Critical Note: The December 31, 2001, grandfather provision remains one of the most significant constraints on hospice expansion in the state of Maryland. This date is fixed in statute and continues to limit where hospices can provide services.
The Senior Soup verified this provision as current through July 2025.
[Source: Justia Maryland Code]
II. Regulatory Framework – Code of Maryland Regulations (COMAR)
Regulatory Update Notice: COMAR is updated quarterly.
While this document reflects regulations current as of July 2025, users should verify the latest amendments through official Maryland sources.
Please note that, under Maryland law, only the printed version of COMAR is legally enforceable.
A. COMAR 10.07.21: Hospice Care Programs
1. General Requirements
Compliance Standards:
- Must meet all federal and State laws and regulations;
- Ancillary services must be provided in accordance with applicable requirements.
2. Pharmacy Services (COMAR 10.07.21.15)
Staffing Requirements:
- Must employ or contract with licensed pharmacist.
Pharmacist Responsibilities:
- Ensure all drugs and biologicals are prescribed, dispensed, administered, stored, and disposed of per applicable laws;
- Oversee drug distribution system;
- Provide consultation on drug interactions.
Operational Requirements:
System to obtain and provide drugs on emergency basis, 24 hours per day, 7 days per week
Implementation Note: Maryland hospice providers can meet this requirement through various arrangements, including:
- On-call pharmacists;
- Contracts with 24-hour pharmacies;
- Properly maintained emergency drug kits (EDKs);
- Combination of the above methods.
- Maintain drug profile for each patient;
- Conduct periodic drug reviews and monitoring;
- Ensure that the interdisciplinary team and the patient/family are informed about the medications.
B. COMAR 10.07.22: Hospice House Requirements
1. Medication Management and Administration (COMAR 10.07.22.13)
General Standards:
- All medications administered consistent with COMAR 10.27.11;
- Medications and treatments per current medical orders;
- Using acceptable professional standards of practice.
Storage Requirements:
- Secure location at proper temperature;
- Original dispensed containers;
- Patient-specific storage.
Documentation Requirements:
- Record at time of administration;
- Medication administration report;
- Survey Focus: Maryland surveyors specifically look for documentation of:
- Pain scale ratings before and after analgesic administration;
- Effectiveness of anxiolytics for agitation;
- Response to anti-emetics;
- Overall symptom control outcomes.
- Report unrelieved symptoms to primary nurse;
- Report side effects, adverse reactions, or errors.
Controlled Substances:
- Count and record at shift changes;
- Double lock system for controlled substances and high abuse potential medications.
[Source: Cornell Law Institute]
2. Restraint or Seclusion Policies (COMAR 10.07.22.18)
Policy Requirements:
- Develop policies and procedures related to restraint and seclusion;
- Train relevant staff per facility policy.
Patient Rights:
- Right to be free from restraint or seclusion imposed as coercion, discipline, convenience, or retaliation.
Permitted Use:
- Only to ensure immediate physical safety of patient, staff, or others;
- Must be discontinued at earliest possible time;
- Least restrictive intervention effective.
Implementation Requirements:
- Written modification to patient’s plan of care.
- Consultation with primary nurse and medical director as soon as possible:
- Federal Requirement: Per 42 CFR § 418.110(n)(11), face-to-face medical director or physician designee evaluation must occur within one hour of restraint initiation;
- Documentation must show time of restraint application and time of consultation.
- Family notification is required each time a restraint is used.
C. COMAR 10.09.35: Medical Assistance Program Hospice Regulations
1. Definitions (COMAR 10.09.35.01)
Provider Requirements:
- Medicare-certified as hospice care provider;
- Meets all State and local licensing requirements;
- Provider agreement with Department.
Interdisciplinary Group Requirements:
- Must include at least:
- Physician;
- Registered nurse;
- Social worker;
- Pastoral or other counselor.
2. Eligibility and Election (COMAR 10.09.35.05)
Certification Requirements:
- Written certification of terminal illness for each election period.
- The initial period requires two physicians: a medical director or a physician member of the interdisciplinary team and an attending physician (if applicable).
- Subsequent periods require one physician.
Provider Changes:
- Participant may designate new provider once per election period.
- Not considered revocation of hospice election.
- Written statement required with: Names of previous and new provider; effective date of change.
Revocation Rights:
- May be revoked at any time for any reason;
- Forfeits remaining days in election period;
- May elect hospice for remaining periods if eligible.
3. Duration of Care (COMAR 10.09.35.04)
Election Periods:
- Available in specific order;
- May be elected separately at different times.
Termination Causes:
- Change in terminal prognosis;
- Relocation where hospice unavailable;
- Patient behavior making care inappropriate;
- Program determination for cause.
III. Maryland Medical Malpractice & Liability Framework
A. General Medical Malpractice Standards
1. Health Care Provider Definition
Maryland law explicitly includes “hospice programs” in the definition of health care providers subject to medical malpractice statutes under Courts & Judicial Proceedings Article, Title 3, Subtitle 2A.
2. Certificate of Qualified Expert Requirements
Filing Requirements:
- Must file within ninety days of complaint;
- Must attest defendant departed from standards of care;
- Departure must have proximately caused injury;
- Extensions are available if the statute of limitations has passed.
Expert Qualifications:
- Cannot devote more than 20% of professional time annually to testimony;
- Must have clinical experience in relevant field.
[Source: Nolo – Maryland Medical Malpractice Laws]
3. Health Care Alternative Dispute Resolution
Mandatory Arbitration:
- Claims over $30,000 must be filed with the Maryland Health Care Alternative Dispute Resolution Office;
- Three-member panel: attorney, health care provider, public member;
- Non-binding process with court appeal rights;
- Waiver available within sixty days.
[Source: Miller & Zois]
B. Wrongful Death in Hospice Context
1. Statute of Limitations
General Rule:
- Three years from when injury was discovered or reasonably should have been discovered.
- Special provisions for minors under the age of eighteen.
[Source: Maryland Injury Law Center]
2. Damage Caps (Current as of 2025)
Non-Economic Damages:
- Current cap: $875,000 (as of 2025);
- Increases $15,000 annually on January 1st;
- Wrongful death with multiple claimants: 125% of standard cap.
Economic Damages:
- No cap on economic damages (medical expenses, lost wages, etc.).
[Source: Rice Law MD]
IV. Maryland Hospice Case Law & Precedents
A. Certificate of Need Cases
Department of Health and Mental Hygiene v. VNA Hospice of Maryland (2007-2008)
Procedural History:
- Court of Special Appeals (2007): Initially upheld Department’s restrictive interpretation;
- Court of Appeals (2008): Reversed, finding bereavement services integral to hospice care.
Key Legal Holdings:
- Hospice care providers must obtain a certificate of need before developing or operating in the state of Maryland;
- Jurisdictional limitations based on historical service provision;
- 2001 grandfather provision limits expansion;
- Bereavement services are an integral part of hospice care, not a separate service.
Additional Relevant Case Law Developments:
While no major hospice-specific precedents have emerged since 2008, several interpretive patterns have developed:
- Jurisdictional Definitions: Administrative interpretations treat “jurisdiction” as county boundaries for certificate of need purposes;
- Emergency Expansions: Limited exceptions recognized for public health emergencies with specific Maryland Health Care Commission authorization;
- Merger Applications: Certificate of need requirements apply to the surviving entity in mergers, limiting service areas to those previously authorized for both entities.
B. Hospice Negligence Standards
Common Violations Leading to Liability:
Care Planning Failures:
- Failing to create an individualized care plan;
- Inadequate initial assessment;
- Generic “peaceful death” plans without specifics;
- Not updating plans based on changing conditions.
Medication Management:
- Administering dangerous dosages;
- Exceeding recommended amounts;
- Inadequate monitoring for overdose symptoms;
- Poor documentation of dosing rationale;
- Failure to document effectiveness.
Supervision and Assessment:
- Failing to provide proper assessments;
- Inadequate supervision of care;
- Not monitoring declining consciousness;
- Missing signs of medication overdose;
- Delayed response to symptom changes.
V. Regulatory Enforcement
A. Maryland Board of Physicians
Authority:
- Derived from Maryland Medical Practice Act;
- Maryland Health Occupations Article, Title 14;
- Board composition: Twenty-two members, including physician and public representatives.
Enforcement Powers:
- Reprimands and mandated education;
- License suspension or revocation.
- Probation and fines;
- Subpoena and investigation authority.
Disciplinary Process:
- Hearings before the Maryland Office of Administrative Hearings;
- Administrative Law Judge evaluation;
- Right to legal representation;
- Appeal to a Maryland Circuit Court.
[Source: Maryland Board of Physicians]
B. Maryland Office of Healthcare Quality (OHCQ)
Oversight Functions:
- Postmortem reviews of hospice deaths;
- Investigation of complaints;
- Regulatory violation citations;
- Quality assurance reviews;
- Annual survey and certification.
Current Scope (as of July 2023):
- Oversees 21,221 providers across forty-seven industries;
- Conducts regular compliance surveys;
- Manages complaint investigations.
Survey Focus Areas:
- Medication management and documentation;
- Care planning individualization;
- Interdisciplinary team function;
- Patient rights compliance;
- Quality assessment and performance improvement.
[Source: Maryland Department of Health OHCQ]
VI. Key Compliance Areas
1. Medication Management
- 24/7 drug availability systems (multiple compliant methods available);
- Double-lock for controlled substances;
- Individual patient drug profiles;
- Proper disposal procedures per EPA/DEA;
- Documentation at administration time;
- Documentation of medication effectiveness (critical for surveys).
[Sources: COMAR 10.07.22.13, § 19-914]
2. Patient Rights
- Freedom from inappropriate restraints;
- Right to revoke hospice election;
- Right to change providers (once per election period);
- Informed consent requirements;
- Appeal rights for denials.
3. Operational Requirements
- Certificate of Need for new programs;
- Jurisdictional service limitations (December 31, 2001, grandfather clause – verified current);
- Licensure under Maryland Health-General Title 19;
- Medicare certification requirements;
- State and federal regulatory compliance.
[Source: § 19-906]
4. Quality Standards
- Individualized care plans required;
- Interdisciplinary team approach;
- Initial and ongoing assessments;
- Documentation standards;
- Family involvement requirements;
- QAPI program implementation.
5. Financial and Billing
- Medical Assistance Program requirements;
- Medicare billing compliance;
- Proper election period management;
- Appeal procedures for denials;
- Anti-fraud compliance;
[Sources: Medicare.gov Hospice Coverage, CMS Hospice Center]
VII. Maryland Hospice Practice Compliance Checklist
For Hospice Providers:
- [ ] Valid Maryland hospice license (general or limited)
- [ ] Medicare certification current
- [ ] CON for each service jurisdiction
- [ ] Written medication policies including disposal procedures
- [ ] 24/7 pharmacy access system documented and tested
- [ ] Emergency drug kit policies and proper maintenance
- [ ] Restraint policies with 1-hour consultation requirement per federal law
- [ ] Staff training records on restraint use
- [ ] Individualized care planning process with regular updates
- [ ] Interdisciplinary team meeting schedule and documentation
- [ ] Quality assurance and performance improvement program
- [ ] Appeals process for patients clearly documented
- [ ] Medication effectiveness documentation protocols
- [ ] Compliance with both state and federal requirements
- [ ] Quarterly COMAR update verification process
Download the Maryland Hospice Provider Compliance Checklist.
For Patients and Families:
- [ ] Understand hospice election periods and benefits
- [ ] Know revocation rights (can revoke anytime)
- [ ] Understand provider change limitations (once per period)
- [ ] Review medication management policies
- [ ] Understand coverage limitations and exclusions
- [ ] Know appeal rights for coverage denials
- [ ] Verify provider credentials and service area authorization
- [ ] Understand billing practices and potential costs
- [ ] Know complaint procedures (OHCQ and Medicare)
- [ ] Understand advance directive requirements
- [ ] Be aware of current damage caps for potential claims
Download the Maryland Hospice Patient Checklist.
VIII. Maryland Hospice Regulatory Updates & Best Practices
Staying Current with Regulations
Essential Resources:
- Maryland Department of Health website for regulation updates;
- Office of Healthcare Quality bulletins and alerts;
- Maryland Hospital Association hospice updates;
- CMS transmittals affecting hospice;
- Professional associations: Hospice and Palliative Care Network of Maryland; National Alliance for Care at Home.
- Quarterly COMAR updates (remember: only printed version is legally enforceable).
Survey Preparation Best Practices:
- Conduct mock surveys using current OHCQ survey tools;
- Review recent survey findings from other Maryland hospices;
- Maintain ongoing compliance monitoring programs;
- Document all quality improvement activities;
- Ensure staff understand documentation requirements;
- Verify federal requirement compliance (especially one-hour restraint consultation).
Common Survey Citations to Avoid
Top Areas of Non-Compliance:
- Incomplete or generic care plans;
- Missing medication effectiveness documentation.
- Delayed interdisciplinary team reviews;
- Inadequate volunteer documentation;
- Missing bereavement follow-up;
- Non-compliance with federal restraint consultation timeframes.
Legal Consultation Recommendations
When to Seek Legal Counsel:
- Before major operational changes;
- When interpreting new regulations;
- For merger and acquisition planning;
- Following adverse survey findings;
- When facing potential litigation;
- To verify current damage cap amounts.
IX. Federal Hospice Integration Requirements
Medicare Conditions of Participation (42 CFR Part 418)
Maryland hospices must comply with all federal requirements in addition to state regulations.
Key areas include:
- Core services provision;
- Contracted services oversight;
- Hospice aide supervision;
- QAPI program requirements;
- Infection control programs;
- Emergency preparedness plans;
- Restraint consultation within one hour (42 CFR § 418.110(n)(11)).
Areas Where State and Federal Hospice Requirements Intersect
- Interdisciplinary team composition;
- Patient rights and responsibilities;
- Quality assessment requirements;
- Medication management standards;
- Documentation requirements;
- Restraint policies (federal one-hour requirement supersedes state “ASAP” language).
X. Additional Resources
Maryland-Specific Resources:
- Maryland Department of Health – Hospice Services;
- Maryland Board of Physicians;
- COMAR Online;
- Maryland Health Care Commission.
Federal Resources:
Legal Resources:
Verification Statement
This document has been thoroughly reviewed and verified against current Maryland statutes, COMAR regulations, and federal requirements as of July 2025.
We have cross-referenced all information with official sources and updated it to reflect current law. We provide source citations throughout for verification purposes.
Disclaimer
This document provides general information about Maryland hospice laws and regulations for educational purposes.
Regulations and interpretations may change, particularly with COMAR’s quarterly update schedule.
For specific compliance questions or legal matters, we strongly recommend consulting qualified healthcare attorneys who are familiar with current Maryland law.
Always verify current requirements with official sources before making operational decisions.
This verified edition provides accurate, educational content about Maryland hospice regulations, designed to help seniors and their families understand the regulatory framework governing hospice care in the state of Maryland.
The Senior Soup has verified all information and included source citations to ensure transparency and facilitate further research.
Ryan Miner, MBA | Co-Founder and Podcast Host | The Senior Soup
Hi, I'm Ryan!
I co-founded The Senior Soup Soup with Raquel Micit in September 2022. Together, we host The Senior Soup Podcast.
I am a community relations manager for Ennoble Care in Maryland, where I am responsible for marketing our home-based primary care healthcare practice.
I have over 15 years experience in healthcare, senior services, senior care, marketing, public policy, and search engine optimization.
I have a MBA from Mount St. Mary's University and a BA from Duquesne University.