Hawaii home health agency license: SHPDA first, then an OHCA survey

Home health or home care: where Hawaii draws the line

Under HAR 11-97.1, “home health services” means skilled nursing plus at least one other therapeutic service, delivered on a visiting basis to a homebound patient in their home. The other service can be physical therapy, speech-language pathology, occupational therapy, medical social services or home health aide services. You must provide at least one of these services directly. You may provide the second and any further services under arrangement with another agency or organization.⁠² A “homebound patient” is someone whose illness or injury restricts them from leaving home without help: crutches, a cane, a wheelchair, a walker, special transportation or another person. A person for whom leaving home is medically contraindicated also counts.⁠²

OHCA has written down how it applies that definition:⁠¹

• Payer, frequency and volume don’t matter. Licensure turns on whether you provide home health services. It does not matter whether Medicare, Medicaid or the patient pays, whether you visit once or twice a year, or whether you serve only one or two clients.
• Some personal care tasks count as therapeutic. Help with dressing changes, medication administration and range of motion “would generally be considered ‘therapeutic’ and home health care.”
• Feeding, bathing and toileting are generally home care. The exception is when the physician or therapist has given specific instructions or procedures for those tasks as part of the client’s treatment.

Non-medical personal care, homemaker help and respite fall under a separate home care agency license under HAR 11-700. Home care, by OHCA’s definition, excludes “nursing services or other clinical professional services normally provided by home health agencies or private duty nursing services.”⁠¹⁰ OHCA says one organization doing both needs separate licenses. It also says the organization must clearly separate its home care clients from its home health patients, “especially for Medicare billing.”⁠¹ The home care license costs $1,500 initially and $1,000 to renew.⁠³ See the Hawaii home care agency guide if you plan to run both.

Operating a home health agency without a license is unlawful under HAR 11-97.1-3(a).⁠² OHCA warns that unlicensed operators may face civil money penalties, imprisonment or both, and should stop providing services until they are licensed.⁠¹

Step one: SHPDA and the certificate of need

“Home Health Agency” is one of the standard non-bed service categories in HAR 11-186-5. Adding a standard service category is a change of service that requires a CON.⁠⁴ By statute, SHPDA may issue a CON only if there is a public need for the service and its cost is reasonable given its benefits and its effect on health care costs.⁠⁵

In practice, OHCA describes two routes, chosen by how you plan to be paid:⁠¹

Either document goes to OHCA with your licensure request.⁠¹ Neither agency publishes how long a no-CON letter takes or what you must submit to get one. Call SHPDA at (808) 587-0788 (1177 Alakea Street, #402, Honolulu) before you sign a lease.⁠⁶ OHCA’s page says applicants who want to take part in Medicare or Medicaid “will need to obtain an approved CON,” and it describes the no-CON letter only for applicants not seeking federal certification. Neither OHCA nor HAR 11-186 says what happens if you are licensed on a no-CON letter and later want to certify. Before you choose the private-pay route, ask SHPDA in writing whether you would need a full CON first, and whether the letter would limit you.

How a CON application moves

SHPDA scores applications on six groups of criteria:⁠⁶

• fit with the State Health Services and Facilities Plan
• need and accessibility
• quality of care
• cost and financial impact
• relationship to the existing health care system
• availability of resources, including staff

SHPDA publishes separate standard and administrative application forms, plus a page for calculating the fee.⁠⁷

• Filing fee. The fee is $200 plus 0.1% of the capital expenditure up to $1,000,000, plus 0.05% of any amount above that. It is non-refundable, and SHPDA will not accept an application unless the fee comes with it.⁠⁴ A home health agency without major capital spending will pay close to the $200 minimum. Use SHPDA’s fee page to calculate the exact amount.
• Completeness. SHPDA decides within 30 days of filing whether your application is complete. If it is not, you have 60 days from SHPDA’s notice to fix it, or the application may be dismissed without prejudice.⁠⁴
• Standard review. A standard application usually goes to three advisory bodies before SHPDA decides: the Subarea Health Planning Council, the CON Review Panel and the Statewide Health Coordinating Council. Their meetings are open to the public, and anyone may submit written testimony or testify.⁠⁶ Which subarea council reviews the application depends on the population your agency will mainly serve: one subarea, several subareas in one county, or the whole state.⁠⁴
• Administrative review. A service change with a capital expense of $1,000,000 or less and an increase in annual operating expense under $500,000 may qualify for the shorter administrative review. So may an additional location of an existing service, or any proposal SHPDA finds will not significantly affect the health care system. SHPDA may still require standard review if it decides that serves the public interest.⁠⁴
• Finality. A decision becomes final only after the period in which any person may request a public hearing for reconsideration.⁠⁴
• Shelf life. A CON is valid for one year from issuance unless SHPDA extends it for good cause. Spending on the project may not exceed the maximum amount approved in the certificate.⁠⁵

SHPDA posts every application and decision online. In 2024 and 2025 it posted applications to establish home health agencies in Lihue (24-05A) and Honolulu (24-11A and 25-09).⁠⁸ Reading recent filings is the most direct way to see what SHPDA expects in a home health need analysis. Many of the posted decision letters are scanned images, so download the PDFs rather than searching them as text.

Moving an agency’s location later also requires a CON, unless SHPDA decides in writing that the move does not significantly affect service to the target group.⁠⁴

What HAR 11-97.1 requires you to have in place

OHCA expects you to meet every licensing requirement, including written policies and qualified staff, at the moment you send your request.⁠¹ The rule is short, so each section matters.

Governance and the clinical manager

• Governing body. A governing body, or designated persons acting as one, holds full legal authority and responsibility for operations, services, finances, the budget, operational plans and the quality program. It must keep minutes of its meetings.⁠²
• Administrator. The governing body appoints the administrator, who reports to it. The administrator runs day-to-day operations, makes sure qualified staff are hired, and makes sure a clinical manager is available during all operating hours. A pre-designated backup, authorized in writing by the administrator and the governing body, stands in when the administrator is unavailable. The backup may be the clinical manager.⁠²
• Clinical manager. The clinical manager oversees all patient care and personnel. They must hold a Hawaii license as a physician, APRN, physician assistant, physical therapist, speech pathologist, occupational therapist, audiologist, social worker or registered nurse.⁠² Every licensed professional definition in the chapter requires a Hawaii license. The one exception is VA clinicians, who may hold a license from another state when caring for VA beneficiaries.⁠²

Professional advisory committee

Policies for nursing and other therapeutic services must come from the governing body or an advisory committee. At minimum, the committee must include:⁠²

• a practicing physician, APRN or physician assistant
• a registered nurse
• a representative of another professional service, such as dietary, OT, PT, social work or speech therapy
• community members

The committee must keep minutes.⁠²

Services and orders

• Nursing must be provided by the agency itself.⁠²
• Every service follows a written order and plan of treatment signed by the patient’s physician, APRN or physician assistant. That practitioner, with your professional staff, reviews the plan as often as the patient’s condition requires, and at least once every two months.⁠²
• Only the attending practitioner may end services. They prepare or approve a written discharge summary. Verbal orders must be countersigned “within a reasonable period of time.”⁠²
• If you don’t provide every service yourself, your policies must explain how you will use other resources. You can arrange those services through written agreements with other licensed home health agencies or contracts with qualified professionals.⁠²
• You must keep a written policy statement covering your scope of services, the conditions under which you offer them, and your geographic coverage. You must serve any qualified patient in your area regardless of race, color or national origin.⁠²

Personnel and training

You need:⁠²

• written job descriptions for each staff category
• written personnel policies given to each employee
• a plan for pre-employment and periodic medical exams, tuberculosis testing or chest x-rays, and immunizations
• an orientation program and continuing in-service education
• periodic performance evaluations

A home health aide must have completed the basic nurse aide course or an equivalent course, plus additional training and supervision for the home health role.⁠² If you plan to certify for Medicare, federal rules add more:⁠¹²

• at least 75 hours of aide training, with at least 16 hours of classroom training before at least 16 hours of supervised practical training
• at least 12 hours of in-service training every 12 months
• a supervisory assessment of aide services at least every 14 days for patients receiving skilled care

Records, quality and infection control

• Clinical records, personnel files, fiscal reports and committee reports must be kept in the agency’s office. If the agency is part of a larger organization, its costs must be easy to identify in the books.⁠²
• You must run an agency-wide, data-driven quality assessment and performance improvement program that covers contracted services. You must also follow standard precautions for infection control.⁠²

Patients’ rights and emergencies

• Patients must be told about the state’s toll-free home health hotline, including its hours and its purpose. Their complaints must be investigated promptly.⁠²
• Your emergency preparedness plan must cover your patient population, continuity of operations, procedures for interrupted services, and a communication plan with contacts for staff, contractors, physicians and volunteers. You must review the plan at least every two years.⁠²

Background checks

HRS 321-15.2 lists home health agencies as healthcare facilities. Applicants are subject to background checks. For an entity, that includes principals, directors, partners and managers who will have access to clients or their records. Every prospective employee or volunteer with direct patient access is also subject to checks, and must consent and, where required, be fingerprinted. After licensure, the department also runs an annual name inquiry into state criminal history records. The Federal Bureau of Investigation and the Hawaii criminal justice data center charge fees for their checks, and those fees may be passed on to the applicant or employee.⁠⁹

Applying to OHCA

1. Get SHPDA’s answer. This is either an approved CON or a letter saying no CON is needed.⁠¹
2. Send a written licensure request. Mail it with a copy of SHPDA’s response to the Office of Health Care Assurance, 601 Kamokila Boulevard, Room 395, Kapolei, HI 96707. OHCA’s page describes a request letter; the rule refers to “forms provided by the department,” so ask OHCA whether a form is now in use.⁠¹⁠²
3. Include the document package. OHCA lists these items:⁠¹
   • your policy and procedure manual covering governing body, personnel, patient care, emergency and disaster plan, infection control, in-service training, medical records, and overall program evaluation
   • contracts for any services not provided by salaried employees
   • licenses and credentials for the agency and its staff
   • your legal name, tax ID number and DBA
   • the physical address, phone and fax of the agency
   • your days and hours of operation
   • the administrator’s name, address, phone, fax and email
4. Wait for acknowledgment and desk review. OHCA acknowledges the request in writing and reviews the documents when they arrive. It contacts you if it has questions. OHCA says that “due to existing contractual obligations,” it may not be able to take on an initial licensure request for several months.⁠¹
5. Pass the initial onsite survey. If your documents are in order, OHCA schedules the survey and returns your materials at the survey.⁠¹ Afterward, OHCA notifies you in writing that you are either in full compliance or must submit a plan of correction.⁠³
6. Pay within 10 days. Once you are notified of full compliance, you have ten days to pay the $2,750 initial fee. Pay by corporate or bank check, or money order, made out to “State of Hawaii OHCA SF”, or electronically if available. OHCA does not accept personal checks or cash, and fees are non-refundable. No license issues until the fee is paid in full.⁠³

The license covers only the named agency at one contiguous geographic location. It cannot be transferred or assigned, so a buyer of an agency needs its own license. You must post the license conspicuously at the agency.⁠²

Medicare, Medicaid and the 2026 enrollment freeze

Medicare and Medicaid certification is voluntary and comes after the state license.⁠¹ OHCA, acting as the State Survey Agency, sets out the Hawaii sequence:⁠¹

• You start out private-pay. Once licensed, you can admit patients, but nothing is reimbursed until you pass the Medicare survey. Until then, you either admit only private-pay clients or absorb the cost of any Medicare or Medicaid clients you take.
• The survey waits for patients. OHCA schedules a Medicare survey only after a written request, and only once you are fully operational and have admitted enough clients for surveyors to judge compliance. OHCA does not set a fixed number; it weighs your size and the client population in your area. If you don’t have enough admissions or records, your application and survey request will be denied.
• One unannounced visit decides it. The survey is unannounced, a single step, and has no revisits. A denial starts the application process over, and OHCA says a new survey may not happen for up to six months.
• Initial surveys come last. Under the national workload priorities OHCA lists, initial certification surveys rank last, behind recertifications, complaint investigations and validation surveys.

On top of that, CMS stopped enrolling new home health agencies, branches and practice locations in Medicare nationwide on May 13, 2026. Only applications that a Medicare contractor received before that date continue.⁠¹³ During the moratorium:⁠¹⁴

• initial applications are denied and must be filed again after it ends
• CMS allows no exceptions for individual providers
• accreditation does not give a new agency deemed status for Medicare participation

Under 42 CFR 424.550(b), an agency that goes through a non-exempt change in majority ownership within 36 months of its initial enrollment must enroll as a new agency. The moratorium blocks that new enrollment, so buying a young agency does not get around it.⁠¹³ The freeze runs for six months and can be extended in six-month increments.⁠¹⁵ As of October 12, 2026, no extension notice had been found, so the first period runs to about mid-November 2026.⁠¹³ CMS left it to each state to decide whether to freeze Medicaid enrollment of home health providers.⁠¹³ Ask Hawaii’s Med-QUEST Division about Medicaid enrollment before you count on Medicaid revenue.

For a founder in Hawaii, the result is that a full CON for a Medicare-certified agency can take months of SHPDA review. That CON is then valid for one year, while Medicare enrollment stays frozen.⁠⁵⁠¹³ Line up the CON timing with the moratorium’s status on the CMS moratoria page before you file.⁠¹⁵

Renewal, inspections and closing

• Renewal. The license must be renewed every two years. File the renewal application 30 days before the expiration date and pay the $2,000 fee at least 30 days before the renewal date. If you don’t file, the license is cancelled automatically when it expires. Not paying the fee forfeits the license.⁠²⁠³
• Inspections. OHCA staff may make unannounced inspections or visits at any time.⁠²
• Enforcement. The director may suspend, revoke, or refuse to issue or renew a license after notice and a chance for a hearing. Violations are handled through administrative proceedings under HRS 321-20.⁠²
• Closing. Before giving up the license voluntarily, notify each patient and the patient’s physician, APRN or physician assistant at least 30 days in advance. Return the license to the department.⁠² SHPDA must also get written notice at least ten days before a provider ends its entire operation. Shutting down completely does not require a CON.⁠⁴

Other Hawaii licenses you may be weighing

If your model is non-medical personal care or homemaker help, the home care agency license applies instead. If you want to house residents rather than visit them, look at the adult residential care home or assisted living facility licenses. Daytime programs fall under the adult day care center certificate of approval. For all of Hawaii’s care licenses, see the Hawaii state page.

Sources

1. 1
   Hawaii Department of Health, Office of Health Care Assurance, Opening a Home Health Agency Checked 12 Oct 2026 · Back to text ↑
2. 2
   Hawaii Department of Health, HAR Chapter 11-97.1, Home Health Agencies (effective September 16, 2022) Checked 12 Oct 2026 · Back to text ↑
3. 3
   Hawaii Department of Health, HAR Chapter 11-103.1, Health Care Facility and Agency Licensure and Certification Fees Checked 12 Oct 2026 · Back to text ↑
4. 4
   Hawaii Department of Health, HAR Chapter 11-186, Certificate of Need Program (compiled August 17, 2019) Checked 12 Oct 2026 · Back to text ↑
5. 5
   Hawaii State Legislature, HRS 323D-43, Certificates of need Checked 12 Oct 2026 · Back to text ↑
6. 6
   State Health Planning and Development Agency, Certificate of Need Program Checked 12 Oct 2026 · Back to text ↑
7. 7
   State Health Planning and Development Agency, Certificate of Need Blank Application Forms Checked 12 Oct 2026 · Back to text ↑
8. 8
   State Health Planning and Development Agency, Certificate-of-Need Applications and Decisions Checked 12 Oct 2026 · Back to text ↑
9. 9
   Hawaii State Legislature, HRS 321-15.2, Background checks Checked 12 Oct 2026 · Back to text ↑
10. 10
    Hawaii Department of Health, Office of Health Care Assurance, Home Care Agency Licensing Checked 12 Oct 2026 · Back to text ↑
11. 11
    Hawaii Department of Health, HAR Chapter 11-700, Home Care Agencies (effective August 10, 2018) Checked 12 Oct 2026 · Back to text ↑
12. 12
    Electronic Code of Federal Regulations, 42 CFR 484.80, Condition of participation: Home health aide services Checked 12 Oct 2026 · Back to text ↑
13. 13
    Federal Register (CMS), Announcement of Nationwide Temporary Moratorium on Medicare Enrollment of Home Health Agencies Checked 12 Oct 2026 · Back to text ↑
14. 14
    Centers for Medicare & Medicaid Services, QSO-26-11: Moratorium on Medicare enrollment of hospices and home health agencies Checked 12 Oct 2026 · Back to text ↑
15. 15
    Centers for Medicare & Medicaid Services, Provider Enrollment Moratoria Checked 12 Oct 2026 · Back to text ↑

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