Maryland Nursing Home and Assisted Living Advance Directive Requirements

Facilities Are Required to Address Your Advance Directive

When you or a loved one is admitted to a Maryland nursing home, assisted living facility, or hospice program, the facility has a legal obligation to address advance care planning. Under state Department of Health regulations, these facilities must complete or review a MOLST (Medical Orders for Life-Sustaining Treatment) form for every newly admitted patient and offer the patient or their healthcare agent the opportunity to participate in its formulation.

This is not optional for the facility. It is a regulatory requirement.

What Happens at Admission

During the intake process, the facility will:

1. Ask whether you have an existing advance directive. If you do, provide a copy for your medical record. If you do not, the facility must inform you of your right to create one.

2. Initiate a MOLST conversation. A licensed clinician (physician, nurse practitioner, or physician assistant) will discuss your treatment preferences and translate them into a MOLST — the medical order that guides clinical staff on CPR, ventilation, hospitalization, and other interventions.

3. Document your preferences in your care plan. Your treatment preferences, advance directive, and MOLST are integrated into the facility's care plan for you, which all staff members must follow.

Why You Should Arrive with Your Own Documents

Facility-generated forms during admission have the same problems as hospital forms: they are completed under time pressure, they prioritize institutional compliance over custom patient preferences, and they may not capture the specific scenarios that matter most to you.

If you arrive at a Maryland nursing home or assisted living facility with a comprehensive advance directive already executed — including treatment preferences, a named healthcare agent, and supplemental instructions for progressive conditions like dementia — the admission process becomes a conversation about your existing wishes rather than a rush to complete paperwork.

The MOLST Review Cycle

The MOLST is not a one-time document. Maryland facilities are required to review the MOLST form:

• At admission or readmission
• When there is a significant change in your health status
• When you or your healthcare agent requests a review
• Periodically as part of ongoing care planning

Each review is a chance to update your treatment preferences as your health evolves. If your parent enters a nursing home with moderate dementia and their condition progresses, the MOLST should be updated to reflect the new clinical reality.

Medicaid Estate Recovery and Nursing Home Care

For many Maryland families, the nursing home admission triggers a second concern beyond medical care: financial exposure.

Maryland's Medicaid program funds long-term care for eligible residents. After the Medicaid recipient's death, the state can seek reimbursement from the estate for the total cost of care provided. However, Maryland law limits this recovery strictly to the probate estate. Assets that pass outside of probate — through beneficiary designations, life estate deeds, or revocable trusts — are not subject to Medicaid recovery.

This means that advance care planning and estate planning should happen before or at the time of nursing home admission, not after. Structuring assets to bypass probate before entering long-term care protects the family home and savings from state recovery claims.

What Your Healthcare Agent Needs to Know

If you are the healthcare agent for a parent or loved one entering a Maryland facility, you will be asked to participate in MOLST conversations and ongoing care planning decisions. You need:

• A copy of the advance directive, so you can reference the patient's documented wishes during facility meetings
• Understanding of the patient's values around quality of life, aggressive treatment, and comfort care
• Awareness that your authority as healthcare agent supersedes facility preferences — you are making decisions on behalf of the patient, not deferring to institutional convenience

The Maryland Advance Directive & Living Will Kit prepares both the patient and the healthcare agent for facility admissions with a dementia progression supplement, MOLST preparation worksheet, and probate-avoidance tools that address the financial exposure nursing home care creates.

See more Maryland guides →