Following an analysis of the number of residents that the assisted living program intends to serve and the individual needs of each resident, the assisted living program shall develop a staffing plan that identifies the type and number of staff needed to provide the services required by this chapter. The assisted living program shall employ or contract with sufficient numbers of staff to comply with the: Requirements of this chapter; Standards of care for the specific conditions of the residents the assisted living program serves; and All other applicable laws and regulations. Resident Care Needs. The resident’s care needs shall determine the: Need, amount, and frequency of nursing overview by the registered nurse; Need for on-site nursing services; and Need for awake overnight staff. The Department may approve a waiver of the requirement for awake overnight staff when the assisted living program has demonstrated to the Department its use of an effective electronic monitoring system. The Department may not approve a waiver for awake overnight staff on an Alzheimer’s Special Care Unit. The assisted living program shall comply with applicable requirements of COMAR 10.27.09. On-Site Staff. The staffing plan shall include on-site staff sufficient in number and qualifications to meet the 24-hour scheduled and unscheduled needs of the residents. When a resident is in the facility, a staff member shall be present. When a resident is expected to return to the assisted living program, a staff member shall be present. A staffing schedule shall: Be maintained on-site; Include the date, shift hours, and identifying name of all staff members scheduled to work; and Be kept on file for 18 months. Awake Overnight Staff. An assisted living program shall provide awake overnight staff when a resident’s assessment using the Resident Assessment Tool indicates that awake overnight staff is required according to instructions on that tool. If a health care practitioner or assessing registered nurse, in the health care practitioner’s or registered nurse’s clinical judgment, does not believe that a resident requires awake overnight staff, the health care practitioner or assessing registered nurse shall document the reasons in the area provided in the Resident Assessment Tool. The assisted living program shall retain this documentation in the resident’s record. Awake overnight staff are required on an approved Alzheimer’s Special Care Unit. Electronic Monitoring Systems. Upon the written recommendation of the resident’s health care practitioner, the assisted living program may apply to the Department for a waiver in accordance with Regulation .09 of this chapter to use an electronic monitoring system instead of awake overnight staff. If an electronic monitoring system is approved by the Department for the assisted living program to use, the licensee shall document the approval of the electronic monitoring system in the area provided on the Resident Assessment Tool. When a resident is assessed or reassessed using the Resident Assessment Tool, the health care practitioner shall review and document the: Need for awake overnight staff if the resident’s previous assessment or review of an assessment indicated awake overnight staff was not necessary at the time; and Continued appropriateness of a waiver to use an approved electronic monitoring system instead of awake overnight staff. The assisted living program shall comply with applicable requirements of COMAR 10.27.09. The Department may not approve a waiver for awake overnight staff on an Alzheimer’s Special Care Unit. On-Site Nursing Requirements. An assisted living program shall provide on-site nursing when a delegating nurse or health care practitioner, based upon the needs of a resident, issues a nursing or clinical order for that service. If an assisted living manager determines that a nursing or clinical order should not or cannot be implemented, the assisted living manager, delegating nurse, and resident’s health care practitioner shall discuss any alternatives that could safely address the resident’s needs. The assisted living manager shall document in the resident’s record this discussion and all individuals who participated in the discussion. If there are alternatives that could safely address the resident’s needs, the assisted living manager shall notify the resident and, if appropriate, the resident’s legal representative, the delegating nurse, and resident’s health care practitioner of the change to the order. The assisted living manager shall document in the resident’s record this change and the date of notification. If an assisted living manager fails to implement a nursing or clinical order without identifying and providing alternatives to the care or service order, the delegating nurse shall notify the resident’s health care practitioner, the OHCQ, and the resident or, if appropriate, the legal representative of the resident. Failure to implement a nursing or clinical order, without demonstrating why the order should not be followed or without identifying alternatives to care, may result in sanctions against the assisted living program and referral of a licensed or certified staff to the appropriate health occupations licensing board. On-site nursing personnel shall work in partnership with the delegating nurse and assisted living program staff to ensure: Adequate assessment of residents; Planning of medical services; and Oversight of nursing activities.