Pennsylvania - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

The Pennsylvania Department of Human Services (DHS), Office of Long-Term Living (OLTL) licenses Assisted Living Residences (ALRs) under 55 Pa. Code Chapter 2800 to provide housing, personal care, and supplemental health care services to adults. Medicaid reimbursement for these services is administered exclusively through the Community HealthChoices (CHC) 1915(b)/(c) waiver program, which operates under a mandatory managed care delivery system.

Before submitting a Human Services License application to the Bureau of Human Services Licensing (BHSL), prospective providers must secure a commercial Certificate of Occupancy from the Pennsylvania Department of Labor and Industry or local code enforcement. Because Medicaid HCBS funding for ALRs flows entirely through CHC Managed Care Organizations (MCOs), licensed facilities must successfully negotiate network contracts with designated regional health plans to serve Medicaid participants.

1. Service Definition and Scope

In Pennsylvania, an Assisted Living Residence (ALR) is defined as a premises providing food, shelter, personal care, assistance or supervision, and supplemental health care services for a period exceeding 24 hours for four or more adults who are not relatives of the operator. ALRs differ from Personal Care Homes (PCH) by requiring larger physical construction, private bathrooms, and the capacity to provide supplemental health care services to allow residents to age in place.

Under the Community HealthChoices waiver, Assisted Living Services bundle personal care, homemaker, chore, attendant care, companion services, and medication oversight into a daily rate. Room and board costs are explicitly excluded from Medicaid reimbursement and must be paid by the resident.

• Target Population: Adults requiring assistance with Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) who do not require 24-hour skilled nursing facility care.
• Physical Plant: Requires private living units with lockable doors, private bathrooms, and individual temperature controls.
• Supplemental Health Care: Facilities must provide or arrange for health care services, including nursing assessments and specialized cognitive support services.
• Excluded Costs: Medicaid HCBS funds cannot be used to cover room and board expenses.
• Service Bundle: Combines 24-hour supervision, personal care, and emergency response into a single residential service.

2. Regulatory and Oversight Agencies

The Department of Human Services (DHS) is the primary umbrella agency governing Medicaid and human services in Pennsylvania. Within DHS, the Office of Long-Term Living (OLTL) manages the Community HealthChoices waiver and oversees the Bureau of Human Services Licensing (BHSL), which issues the physical facility licenses.

Medicaid provider enrollment is handled through the Provider Reimbursement and Operations Management Information System (PROMISe), while actual service authorization and quality oversight are delegated to the contracted CHC Managed Care Organizations.

• Licensing Authority: DHS Bureau of Human Services Licensing (BHSL) [https://www.pa.gov/agencies/dhs/programs-services/provider-licensing]
• Waiver Administration: DHS Office of Long-Term Living (OLTL) [https://www.pa.gov/agencies/dhs/about/departments-and-offices/office-of-long-term-living]
• Medicaid Enrollment: DHS Provider Enrollment (PROMISe) [https://www.pa.gov/agencies/dhs/resources/for-providers/provider-enrollment-information]
• Managed Care Oversight: Community HealthChoices (CHC) [https://www.pa.gov/agencies/dhs/programs-services/community-healthchoices]
• Building Codes: Pennsylvania Department of Labor and Industry [https://www.dli.pa.gov]

3. Gatekeeping Prerequisites: Who Can Even Apply

Pennsylvania imposes strict physical plant and administrative prerequisites before an ALR license application is accepted. The facility must be fully constructed or renovated to meet commercial building codes before BHSL will process the licensure packet.

For Medicaid participation, the state's transition to mandatory managed care means that obtaining a license and a PROMISe ID does not guarantee patient volume. Providers must secure network contracts with the specific CHC MCOs operating in their geographic zone.

• Certificate of Occupancy: Must obtain a commercial Certificate of Occupancy for an I-1 or similar institutional use group from the PA Dept. of Labor and Industry or local code official before applying.
• Administrator Certification: The facility must hire an Administrator who has completed the 15-hour ALR course and PCH orientation prior to licensure.
• Managed Care Contracting: Must successfully credential and contract with regional CHC MCOs (e.g., UPMC, PA Health & Wellness, AmeriHealth Caritas) to bill Medicaid.
• Zoning Approval: Must secure local municipal zoning approval for a congregate care facility.
• Financial Viability: Must demonstrate financial stability and submit a business plan as part of the initial BHSL application.

4. Licensure and Certification Requirements

ALRs are licensed under 55 Pa. Code Chapter 2800. The application process requires submitting a comprehensive packet to the BHSL Regional Licensing Office, followed by an initial on-site inspection to verify physical plant compliance and policy implementation.

Facilities must demonstrate compliance with stringent physical requirements, including minimum square footage for living units, emergency disaster plans, and specific staffing ratios based on resident acuity.

• Application Form: Submit the Application for a Human Services License to BHSL.
• Regulation Citation: Must comply with all standards in 55 Pa. Code Chapter 2800.
• Initial Inspection: BHSL conducts a comprehensive on-site survey prior to issuing a regular license.
• Plan of Correction: If violations are cited during the initial inspection, an acceptable Plan of Correction must be approved before licensure.
• License Renewal: Licenses are typically issued for 12 months and require annual renewal and inspection.

5. Medicaid Provider Enrollment

Once licensed by BHSL, the facility must enroll as a Pennsylvania Medical Assistance provider through the PROMISe portal. This establishes the provider's base Medicaid ID, which is required before MCOs will execute a network contract.

Providers must enroll under the specific Provider Type and Specialty Code designated for Assisted Living under the CHC waiver, paying the required federal application fee and undergoing screening.

• Enrollment Portal: Submit applications electronically via the PROMISe provider portal [https://promise.dpw.state.pa.us].
• Provider Type: Must enroll using the specific Provider Type designated for HCBS Waiver Providers (typically PT 59 or 51 depending on exact billing setup).
• Application Fee: Must pay the ACA-mandated institutional provider application fee unless waived by Medicare enrollment.
• Revalidation: Medicaid enrollment must be revalidated every five years.
• MCO Credentialing: After PROMISe enrollment, providers must complete separate credentialing applications for each CHC MCO.

6. Staffing, Training and Background Checks

Chapter 2800 regulations mandate specific qualifications for ALR administrators, direct care staff, and supplemental health care personnel. The facility must have a licensed nurse and a dietician available.

All staff with direct resident contact must undergo comprehensive background checks in accordance with the Older Adult Protective Services Act (OAPSA) prior to employment.

• Administrator Qualifications: Must hold a valid ALR Administrator certificate, requiring a 15-hour specific course and passing a competency test.
• Direct Care Staff: Must be at least 18 years old, have a high school diploma or GED, and complete initial and annual training.
• Criminal Background Checks: Must obtain Pennsylvania State Police criminal history clearances for all staff.
• FBI Clearance: Required for staff who have not been PA residents for the consecutive two years prior to employment.
• Nursing Staff: Must employ or contract with a Registered Nurse (RN) or Licensed Practical Nurse (LPN) to oversee supplemental health care.

7. Documentation, Policies and Records

ALRs must maintain extensive documentation to satisfy both BHSL licensing surveyors and CHC MCO quality auditors. This includes resident-specific records and facility-wide operational policies.

A core requirement is the development of a comprehensive support plan for each resident, detailing their medical, personal care, and cognitive support needs, updated annually or upon a significant change in condition.

• Resident Support Plan: Must develop and maintain an individualized support plan as defined in 55 Pa. Code Chapter 2800.
• Medical Evaluation: Each resident must have a medical evaluation completed by a physician within 60 days prior to admission or 15 days after.
• Resident Rights: Must provide and document receipt of the resident rights and grievance procedures.
• Disaster Preparedness: Must maintain a written emergency disaster plan approved by local emergency management.
• Medication Administration Records (MAR): Must maintain strict documentation of all medications administered by trained staff.

8. Billing, Rates and Claims

Because ALR services are covered under the managed Community HealthChoices waiver, billing is not submitted directly to the state's PROMISe system for fee-for-service payment. Instead, claims are submitted to the resident's assigned CHC MCO.

Rates are negotiated between the provider and the MCO, though they are influenced by the state's actuarial rate-setting for the waiver. Providers must collect room and board payments directly from the resident.

• Claims Clearinghouse: Claims are submitted via EDI or MCO-specific provider portals (e.g., NaviNet).
• Prior Authorization: All Medicaid ALR services require prior authorization from the CHC MCO based on the participant's Person-Centered Service Plan.
• Room and Board: Providers must execute a separate resident agreement detailing the private-pay room and board charges.
• Procedure Codes: Billed using specific HCPCS codes (e.g., T2031) as defined in the MCO provider manual.
• Timely Filing: Claims must typically be submitted within 180 days of the date of service, depending on the specific MCO contract.

9. Approval Sequence and Timeline

The end-to-end process from securing a building to billing Medicaid can take 9 to 18 months. The sequence is strictly linear: physical plant approval, followed by state licensure, followed by Medicaid enrollment, followed by MCO contracting.

BHSL advises that the initial licensing process alone takes a minimum of 90 days from the date a complete application is submitted.

• Step 1: Obtain Certificate of Occupancy from L&I or local code enforcement (Timeline varies by construction).
• Step 2: Submit Human Services License application to BHSL (90+ days for processing and inspection).
• Step 3: Submit PROMISe enrollment application (30-60 days).
• Step 4: Apply for CHC MCO network inclusion and credentialing (90-120 days).
• Step 5: Receive MCO authorizations and commence Medicaid billing.

10. Common Denials and Survey Findings

Licensure applications are frequently delayed due to incomplete physical plant requirements or failure to secure the correct I-1 Certificate of Occupancy. BHSL will not schedule an initial inspection until all structural prerequisites are met.

During operations, common survey citations involve medication administration errors, incomplete resident support plans, and failure to maintain required staffing ratios.

• Occupancy Gate: Application rejected if the Certificate of Occupancy does not match the requested licensed capacity or use group.
• Administrator Credentials: Delay if the designated Administrator has not completed the specific 15-hour ALR course.
• Medication Errors: Frequent citations for staff failing to properly document medication administration on the MAR.
• Background Check Gaps: Citations for allowing staff to begin direct care work before OAPSA clearances are fully returned.
• MCO Network Closure: MCOs may deny network contracts if they determine they have adequate ALR capacity in a specific county.

11. Key Contacts and Resources

Prospective providers should utilize the official resources provided by the Department of Human Services and the Office of Long-Term Living to navigate the licensure and enrollment process.

Regional BHSL offices handle the day-to-day inspection and licensing tasks, while PROMISe provider enrollment handles the Medicaid ID issuance.

• DHS Provider Licensing: [https://www.pa.gov/agencies/dhs/programs-services/provider-licensing]
• PROMISe Provider Portal: [https://promise.dpw.state.pa.us]
• Community HealthChoices Information: [https://www.pa.gov/agencies/dhs/programs-services/community-healthchoices]
• PA Department of Labor and Industry: [https://www.dli.pa.gov]
• Chapter 2800 Regulations: Available via the Pennsylvania Code website [http://www.pacodeandbulletin.gov]

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