North Dakota home health agency license: HHS rules, staff and the Medicare freeze

The RN-plus-one test: what makes you a home health agency

North Dakota does not license an agency based on whether it does “skilled” or “non-skilled” work. It licenses a defined service mix. Under N.D.C.C. 23-17.3, home health services “must include the services of a currently licensed registered professional nurse and at least one other therapeutic service.” These services may be provided only with the approval of a licensed physician or an “allowed practitioner,” which the statute defines as a physician assistant or advanced practice registered nurse.⁠¹ The statute lists five therapeutic services:⁠¹

• skilled nursing care
• medical social services
• home health aide services
• physical, occupational or speech therapy
• respiratory therapy

Under the minimum licensing standards, you must provide skilled nursing and at least one of the others “on a regular basis.”⁠¹ The agency must also keep plans of treatment and clinical notes that prove services “are actually provided and not merely listed as being offered.”⁠¹ A license built on a therapy line that you never staff will not hold up at survey.

Several things sit outside this license:

• Supportive services. The statute defines homemaker services, companion services, nutritional guidance, medical supplies and appliances, and specimen collection as “supportive services,” which are separate from therapeutic services.⁠¹ Because the statute requires a registered nurse plus another therapeutic service, an agency offering only these non-medical services falls outside this chapter. Agencies paid by HHS for clients on state-funded programs enroll as Qualified Service Providers (QSPs) instead.⁠¹² Since June 11, 2026, North Dakota Medicaid has paused new QSP agency enrollments in Burleigh and Cass Counties for six months, extendable in six-month periods.⁠¹³ See non-medical home care.
• The name. The rule bars anyone from using the terms “home health agency” or “home health services” without a license.⁠² A companion-care business should not market itself under those words.
• Hospice. Hospice requires its own hospice program license under N.D.C.C. 23-17.4. That license is also required just to advertise or present yourself as a hospice.⁠⁷
• Hospital and other parent organizations. When a hospital’s home care department applies, the department itself is licensed as the agency. Its activities and spending must be identifiable in the parent’s records.⁠²

There is no certificate-of-need step. N.D.C.C. 23-17.3-03, the former certificate-of-need requirement for home health, was repealed in 1995.⁠¹

Medicare: a small market and a national freeze

The CMS iQIES list that HHS posts shows 20 Medicare-certified home health agencies statewide, as of a report run July 29, 2026.⁠⁸ A state license on its own does not let you bill Medicare.

Effective May 13, 2026, CMS imposed a six-month nationwide moratorium on Medicare enrollment of home health agencies. No new agencies, branches or practice locations are enrolled unless the Medicare contractor received the application before that date.⁠⁹ CMS’s survey memo to the states adds that, during the moratorium, accreditation from a CMS-approved accrediting organization “will not serve as the basis for Medicare participation through deemed status.”⁠¹⁰ The moratorium can be extended in six-month increments.⁠¹¹ A Federal Register search on October 13, 2026 found only the May 15, 2026 announcements, so the first term runs to mid-November 2026. Check the CMS moratoria page before you plan around a Medicare start date.⁠¹¹

The federal notice leaves Medicaid and CHIP moratoria to each state.⁠⁹ North Dakota Medicaid’s list of state-initiated moratoria effective June 11, 2026 names non-emergency medical transportation, QSP and developmental disability agencies, not home health agencies.⁠¹³ Ask Medicaid provider enrollment whether that list has changed before you plan a Medicaid start date.

North Dakota’s rule says that where the state chapter conflicts with federal requirements, “the more stringent shall apply.”⁠² If you plan to seek Medicare certification once enrollment reopens, build your policies to the federal conditions of participation from the start.

Hire two people before you apply

The rule makes the governing body (the owner, board or other group legally responsible for the agency) responsible for employing a qualified administrator. That person must be designated in writing and be responsible for staffing, the accuracy of public information and the budget.⁠²

One person may hold both roles if they meet both sets of qualifications.⁠² The statute adds that a supervising physician or supervising RN must be employed full time and that physician or RN supervision must be available “during all hours of operation.”⁠¹ An RN must be reachable by telephone during operating hours and whenever services are being delivered.⁠²

You must notify HHS in writing within 30 days if the administrator, other administrative staff named on the annual licensure application, or the nurse executive changes.⁠²

What HHS checks before it issues the first license

Under 33-03-10.1-03, HHS may not approve an initial license until three things have happened.⁠²

1. A complete application. It must describe every service you will provide and the geographic areas your staff will serve.⁠²
2. An inspection or investigation. HHS reviews the agency for compliance with the chapter.⁠²
3. A fitness finding. You must give HHS evidence that your financial resources and revenue sources “appear adequate” to staff and run the agency. You must also file two signed, notarized statements covering the five years before the application date.⁠²
   • The first lists every proceeding in which the applicant was involved that resulted in a limitation, suspension, revocation or refusal of an agency license, or in a Medicare or Medicaid decertification.
   • The second lists every criminal proceeding in which the licensee, or any 5% shareholder, officer, director, partner or other controlling person, was convicted or had a nolo contendere plea accepted for an offense related to running or owning an agency.

You must also disclose the name, address and position of everyone with a 5% or greater ownership interest.⁠² The statute separately requires for-profit corporations to keep the names and addresses of corporate officers and of anyone holding 10% or more on file.⁠¹ An applicant whose license was previously suspended, revoked or denied must show that the reasons no longer exist and will not recur.⁠²

You may not accept patients until the initial license is issued.⁠²

Filing the application online

HHS takes home health applications through its Health Facilities Licensing online services portal. The same portal handles changes, renewals and license printing.⁠⁴

1. Start the Application for Home Health Agency

   Choose either “Initial Application” or “Ownership Change Application.” The first page asks for the agency’s official name, any doing-business-as name, the NPI number, the physical and mailing addresses with county, a contact email, and phone and fax numbers. You also create a password that you will reuse for later changes, renewals and license printing.⁠⁶ Having an NPI ready before you start saves a return trip.

2. Sign once

   The form requires only one signature.⁠⁵

3. Wait for review

   Once HHS approves the application, it emails the facility contact. You then print the license from the website.⁠⁵ The rule requires you to display the license conspicuously in the agency.⁠²

The Health Facilities Unit is at 1720 Burlington Drive, Suite A, Bismarck, ND 58504-7736; phone (701) 328-2352.⁠⁴ HHS publishes no processing timeline for home health applications.

Fees

N.D.C.C. 23-17.3 and N.D. Admin. Code 33-03-10.1 do not set a dollar fee for a home health license, and none is published on HHS’s home health page or on the first page of the online application (checked October 12, 2026).⁠¹⁠²⁠³⁠⁶ The official sources do not say whether HHS charges an application or annual license fee. Ask the Health Facilities Unit at (701) 328-2352 for the amount, the payment method and whether a fee is due before the initial license issues.

The paperwork your governing body must have in place

The rule lists in unusual detail what the governing body must adopt. HHS can examine these records at any announced or unannounced review.⁠²

• Bylaws (or their equivalent), reviewed every year.⁠²
• An overall plan and budget, including an annual operating budget and a capital expenditure plan.⁠²
• An office that is adequately equipped and meets local ordinances and fire regulations. This is the only physical-plant requirement in the chapter.⁠²
• An organizational chart running from the governing body to the patients, with a description of each service, policies and procedures for each service, job descriptions for each discipline, and a description of how patient records are kept.⁠²
• Admission and care policies. You may accept only patients whose needs you can meet. The patient’s physician must review the plan of care at least every two months when therapeutic services are ordered. Supportive services may run under an RN-signed care plan without a physician’s order when the patient needs no therapeutic services.⁠²
• Personnel files. These must show that you checked state registries and licensure boards before hiring. They also hold orientation and training records, license verification, annual performance reviews and aide competency evaluations.⁠²
• A written patient rights notice, given during the initial evaluation visit before treatment begins. It must explain how much Medicare, Medicaid or other sources are expected to pay. If payment sources change, you must tell the patient orally and in writing within 30 days of learning of the change. The notice must also give the HHS Home Health Hotline, (800) 545-8256.⁠²⁠³
• Contracts. Any service bought from non-employees or other agencies needs a contract signed by both parties. It must cover 13 listed points, including that only your agency accepts patients and only your agency bills. Contracts must be reviewed every year.⁠²
• A quality assessment program with a written plan, plus one documented performance improvement project each year.⁠²
• CLIA compliance under 42 CFR part 493 if you do any laboratory testing at all, regardless of how often or how complex.⁠²

Clinical records must be kept in one central place at the parent or branch office. Entries must be written within 24 hours. Records must be kept for 10 years after discharge, or 7 years after a patient’s death. For minors, records are kept through the age of minority plus those periods.⁠²

Branch offices operated under the same management are licensed under the parent agency’s license. A branch must be close enough to share administration, supervision and services.⁠²

Home health aides: training, competency and supervision

If home health aide services are your second therapeutic service, the aide rules shape your hiring. Before working alone, every aide, whether employed or contracted, must complete either a training and competency evaluation program or a competency evaluation program.⁠²

An agency that has faced state or federal enforcement action, other than a citation of deficiencies, in the past two years may not run its own aide training program.⁠²

All staff must receive training every year on infection prevention and control (including universal precautions), patient rights, and safety and emergency procedures.⁠²

Surveys, corrections and sanctions

HHS may review your agency at any time. It can make an announced or unannounced onsite visit, which may include record review, staff interviews and home visits with the patient’s permission, or it can ask for written documentation.⁠² Renewal depends on compliance found in “periodic unannounced onsite surveys.”⁠²

After a survey with deficiencies:

1. Plan of correction within 10 calendar days

   of receiving the deficiency statement. The plan must explain how you will fix the problem for affected patients, find other patients at risk, prevent it from recurring and monitor the fix. HHS can direct a plan of correction if yours is not acceptable.⁠²

2. Corrections within 60 days

   of the survey completion date, unless HHS sets another schedule.⁠²

Grounds for denial, suspension or revocation include deficiencies that put patients in danger, repeating the same violation within 24 months, failing to carry out a plan of correction, fraud in obtaining a license, and lending or borrowing another agency’s license.⁠² Instead of a full license, HHS can issue a provisional license for up to 90 days. That license can be renewed only once.⁠²

Sanctions are public in a way that is particular to North Dakota. HHS notifies the county social service board in every county you serve, and each board posts the agency’s name and the sanction in its office. You must also post HHS-supplied sanction notices at all agency entrances and exits. HHS can require you to buy print advertising to publicize the sanction.⁠² You have 10 days to request reconsideration, which must dispute each violation specifically; having fixed a violation is not a valid basis.⁠² An appeal is due by 5:00 p.m. on the 31st day after the reconsideration decision, and an appeal does not delay the remedy.⁠²

Renewal and changes during the year

The initial license lasts no more than one year and expires December 31 of the year it is issued. Renewal licenses also expire every December 31.⁠² HHS opens online renewal (“Application for Relicensure”) from October 1 through December 31 each year.⁠⁴ The statute also requires every agency to file an annual description of its operations with HHS: ownership, administrative personnel, location, and the nature and extent of its programs.⁠¹

Licenses cannot be sold, assigned or transferred.⁠² You must notify HHS in writing at least 30 days in advance of any of these changes:⁠²

• a change of ownership, or a lease that transfers operating rights
• a new agency name
• adding or dropping a service
• changing the geographic area you serve

The portal has a separate change form for addresses, personnel and services.⁠⁴ Remember that dropping your only non-nursing therapeutic service would take you below the statutory minimum.⁠¹

Rule changes since 2025

Sections 33-03-10.1-01 (definitions), -10 (governing body), -11 (quality assessment and performance improvement) and -14 (nursing services) were amended effective October 1, 2025. The rest of the chapter dates from January 1, 1998.⁠² Read the 2025 text of the governing body and nursing sections, not older copies.

The statute now lets a physician assistant or APRN approve home health services.⁠¹ However, the rule’s medical services section (33-03-10.1-13, unchanged since 1998) still refers only to the patient’s physician.⁠² The rule has not been amended to match, so the official sources do not say how HHS treats orders from a physician assistant or APRN under that section. Ask the Health Facilities Unit whether it accepts allowed-practitioner orders for the treatment plan before you write your policies.

If you are weighing other North Dakota care licenses, see the foster home for adults license for care of up to four adults in a private residence, and the assisted living facility license. Both are covered on the North Dakota state page.

Sources

1. 1
   North Dakota Legislative Branch, N.D.C.C. ch. 23-17.3, Home Health Agency Licensure Checked 12 Oct 2026 · Back to text ↑
2. 2
   North Dakota Legislative Branch, N.D. Admin. Code ch. 33-03-10.1, Home Health Agencies Checked 12 Oct 2026 · Back to text ↑
3. 3
   North Dakota Department of Health and Human Services, Home Health Agencies Checked 12 Oct 2026 · Back to text ↑
4. 4
   North Dakota Department of Health and Human Services, Health Facilities Licensing Online Services Checked 12 Oct 2026 · Back to text ↑
5. 5
   North Dakota Department of Health and Human Services, Application for Home Health Agency Checked 12 Oct 2026 · Back to text ↑
6. 6
   North Dakota Department of Health and Human Services, Application to Operate a Home Health Agency (online form) Checked 12 Oct 2026 · Back to text ↑
7. 7
   North Dakota Legislative Branch, N.D.C.C. ch. 23-17.4, Hospice Programs Checked 12 Oct 2026 · Back to text ↑
8. 8
   North Dakota Department of Health and Human Services, Name and Address Listing Report: North Dakota home health agencies (iQIES, run July 29, 2026) Checked 12 Oct 2026 · Back to text ↑
9. 9
   Federal Register (Centers for Medicare & Medicaid Services), Announcement of Nationwide Temporary Moratoria on Enrollment of Home Health Agencies (HHAs) Checked 12 Oct 2026 · Back to text ↑
10. 10
    Centers for Medicare & Medicaid Services, QSO-26-11: Hospice and HHA enrollment moratoria Checked 12 Oct 2026 · Back to text ↑
11. 11
    Centers for Medicare & Medicaid Services, Provider Enrollment Moratoria Checked 12 Oct 2026 · Back to text ↑
12. 12
    North Dakota Department of Health and Human Services, Qualified Service Providers Checked 12 Oct 2026 · Back to text ↑
13. 13
    North Dakota Department of Health and Human Services, Provider Enrollment Moratoria Checked 12 Oct 2026 · Back to text ↑

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