Virginia home health license: the VDH home care organization license for skilled care

What counts as home health under an HCO license

The statute defines home health services as services “provided by or under the direct supervision of any health care professional under a medical plan of care” in a patient’s residence, on a visit or hourly basis, for people who have or are at risk of injury, illness or a disabling condition ⁠¹. Under 12VAC5-381-300, a home health program must include at least one of the following ⁠¹⁵:

• nursing services;
• physical therapy;
• occupational therapy;
• speech therapy;
• respiratory therapy;
• medical social services.

That is a lower bar than Medicare’s. The rule’s own definition of a “home health agency” points to the federal standard: skilled nursing plus at least one other therapeutic service, and the capitalization requirements in 42 CFR 489.28 ⁠⁹. A therapy-only organization can therefore hold a Virginia HCO license for skilled services even though it would not qualify as a Medicare home health agency.

A “client’s residence” includes the client’s own house or apartment, a relative’s home, or an assisted living facility. It does not include a hospital, nursing facility or other extended care facility ⁠⁹. Your nurses can therefore see clients who live in a Virginia assisted living facility under your HCO license.

The same license covers the other two service lines:

• Personal care. Hands-on help with activities of daily living (bathing, dressing, toileting, transferring, continence, eating). Under the rule, a registered nurse must supervise it ⁠⁸. Non-medical founders should read the Virginia HCO personal care guide.
• Pharmaceutical services. Dispensing and administering drugs and parenteral nutritional support in the home ⁠¹. Home infusion falls under 12VAC5-381-350. It requires written infusion policies and an RN trained in infusion therapy who supervises medication administration by staff ⁠⁸.

Who is outside the license

The statute and rule exempt the following ⁠²⁠¹⁰:

• A single licensed professional working alone under a medical plan of care, for example a nurse or therapist in solo practice licensed under Title 54.1.
• An individual hired directly by the client or by someone acting for the client.
• Organizations providing only housekeeping, chore or beautician services.
• Providers of only homemaker, chore or companion services as the rule defines them. Homemaker services may include limited help, such as fastening clothing or steadying a client while walking. They exclude feeding, bed baths, transferring, lifting, and putting on braces ⁠⁹.
• A business that only refers clients to independent providers and advertises itself that way. Such a business is not treated as holding itself out as an HCO ⁠⁷.

Once you hire a nurse or therapist as staff and send them to patients, you are an HCO. Owning, operating or managing an unlicensed HCO is a Class 6 felony, and the Commissioner may ask the Attorney General to seek an injunction ⁠⁶. It is also unlawful to advertise yourself as an HCO, or to imply that you are licensed to provide home health services, before you hold a license ⁠⁷.

There is no certificate of public need. Virginia’s COPN list covers hospitals, nursing homes, certain intermediate care facilities and specified outpatient and imaging centers. Home care organizations are not on it ⁠¹⁹.

State license first, Medicare second, then an optional exemption

Virginia sets the order of steps in law:

1. Get the HCO license

   Anyone who plans to seek federal certification or national accreditation must “first obtain state licensure” ⁠¹⁰.

2. Serve clients

   You must “provide services to clients before applying for national accreditation or federal certification” ⁠¹⁰.

3. Get Medicare certification or CMS-recognized accreditation

4. Optionally, leave state licensure

   After initial licensure, an HCO that is certified under Medicare or Medicaid, accredited by a CMS-recognized organization, or licensed for hospice is exempt from the HCO article ⁠². You file a written request with a one-time $75 processing fee ⁠¹⁰⁠¹².

The exemption has limits. Exempt organizations remain subject to OLC complaint investigations ⁠¹⁰. Virginia’s barrier-crime, sworn-disclosure, background-check and drug-free-workplace rules still apply to organizations exempt through Medicare/Medicaid certification or CMS-recognized accreditation ⁠⁴. While a licensed HCO keeps its Medicare certification or accreditation, the state may inspect it “only to the extent necessary to ensure the public health and safety” ⁠²⁵.

OLC’s Home Care and Hospice Unit also conducts federal certification surveys in Virginia. VDH directs Medicare enrollment questions to CGS Administrators at 877-299-4500 ⁠¹⁶. An older OLC memo on accreditation says CMS ranks initial certification surveys of new providers as its lowest survey priority, so a state survey may take a long time to schedule. It calls deemed-status accreditation (CHAP, The Joint Commission or ACHC) “likely to be the fastest route.” The memo also states that before the initial survey you must have completed your OASIS test and admitted at least 10 skilled patients, with at least 7 receiving services on the survey day ⁠¹⁸. The memo dates from a 2007 CMS directive and was posted in 2016, but CMS’s State Operations Manual, Chapter 2, still says a prospective home health agency should have served at least 10 patients before the survey, with at least 7 of them receiving care at the time of the survey ⁠²⁸. Ask OLC or your accrediting body whether the manual’s reduced minimum for medically underserved areas could apply to your service area.

The Medicare freeze in effect since May 13, 2026

Effective May 13, 2026, CMS stopped enrolling new home health agencies, branches and practice locations in Medicare nationwide. Only applications that a Medicare contractor received before that date are still being processed ⁠²⁰. CMS’s survey memo adds these points ⁠²¹:

• Initial applications filed during the moratorium are denied and must be filed again after it ends.
• CMS regulations allow no individual exceptions.
• During the moratorium, accreditation from a CMS-approved organization does not give a new agency Medicare deemed status.

The moratorium runs for six months and can be extended in six-month increments ⁠²². As of October 12, 2026, the only Federal Register notices found were the May 15 announcements, so the first period ends around mid-November 2026. An agency that goes through a non-exempt change in majority ownership within 36 months of its first enrollment must enroll as a new agency, which the moratorium blocks. That means buying a young agency does not get you around the freeze. Agencies that apply within 6 months after the freeze is lifted are assigned to “high” screening ⁠²⁰.

CMS left Medicaid and CHIP moratoria to each state ⁠²⁰. Searches of the DMAS and Virginia Medicaid bulletin pages on October 12, 2026 found no notice restricting Medicaid enrollment of new home health providers. Ask DMAS provider enrollment before you plan around Medicaid revenue.

The state license itself is not frozen. You can still get licensed, serve private-pay clients and build the census you need before a Medicare survey. Under Virginia’s rule, you must serve clients before applying for certification anyway ⁠¹⁰.

Money you must prove up front

Section 32.1-162.9(D) and 12VAC5-381-190 require two financial items with every initial application ⁠³⁠¹³:

• A detailed operating budget showing projected operating expenses for the three months after the license is issued.
• Proof of reserve operating funds sufficient to run the organization for those same three months. Acceptable forms are cash, cash equivalents, borrowed funds that are immediately available, or an immediately available line of credit. Proof means a current balance sheet, a letter from a bank officer where the funds are held, or a lender’s letter of credit showing the amount available.

Once you are licensed, you must keep GAAP books, have an independent CPA audit your financial records at least every three years, and document controls against theft and embezzlement ⁠¹³. At renewal, VDH may not ask for financial documents beyond those required for initial licensure ⁠³.

Insurance minimums

Under 12VAC5-381-210, you must carry the following at all times ⁠¹⁴:

VDH says umbrella and excess liability policies may be used to meet these minimums ⁠¹⁶. The statute makes failure to maintain the coverage grounds for revocation ⁠⁵. Contractors who provide services for you also need liability insurance and crime coverage or a fidelity bond, and your written contract with them must require it ⁠⁸.

Who has to run it

Administrator. The governing body appoints the administrator. That person needs at least one year of training and experience in direct health care service delivery, plus at least one year within the last five years of supervisory or administrative management experience in home health care or a related health program ⁠⁸. The administrator must be your employee, and may also serve as director of nursing if qualified for both roles ⁠⁹. The administrator or a designee must be available at all times during operating hours and for emergencies ⁠⁸.

Director of skilled services. This must be a physician licensed by the Virginia Board of Medicine or a registered nurse, with experience suited to the services you offer. This person directs the availability, quality and staffing of skilled services ⁠¹⁵.

Clinicians. The rule sets these requirements ⁠⁸:

• Nursing is provided by RNs or LPNs. An RN may delegate tasks only as the Board of Nursing allows (18VAC90-20-420 through -460).
• Therapy is provided by Virginia-licensed therapists. An occupational therapy assistant must hold NBCOT certification, and a physical therapy assistant must be licensed by the Virginia Board of Physical Therapy.
• A medical social worker needs at least a bachelor’s degree in social work, sociology or psychology and two years of case work or counseling experience.

Governing body and QI committee. The governing body decides which services you offer, approves policies every year, and must set up a quality improvement committee ⁠⁸. The committee must include:

• the director of skilled services or an RN;
• a member of the administrative staff;
• a representative of each service, including contracted services;
• someone who can represent clients’ rights and concerns, such as a client or a client’s family member.

Results go to the governing body once a year ⁠⁸.

Aides and background checks

The rule calls unlicensed aides “home attendants.” They must speak, read and write English and meet one of these qualifications ⁠⁸:

• completed an RN or LPN education program;
• completed a nurse aide program approved by the Board of Nursing;
• hold Virginia CNA certification;
• are enrolled in a nursing program and have completed a clinical course;
• passed a competency evaluation meeting 42 CFR 484.36(b).

The Department of Medical Assistance Services personal care aide curriculum qualifies an aide for personal care work only, not for skilled services ⁠⁸. An aide assisting with skilled services must receive written care instructions from the responsible professional before the first visit. Each aide needs at least 12 hours of in-service training per year ⁠⁸.

For every compensated employee, the rule and statute require the following ⁠⁴⁠⁸:

• A sworn disclosure statement of criminal convictions and pending charges, in any state.
• An original criminal record report from the Virginia State Police Central Criminal Records Exchange, obtained within 30 days of employment. You may not accept a report dated more than 90 days before the hire date.
• No direct patient contact until the report arrives, unless the new hire works under the direct supervision of an employee whose check is complete.
• A barrier-crime screen. You may not hire anyone convicted of an offense in clause (i) of the barrier-crime definition in § 19.2-392.02. The one exception is a single misdemeanor not involving abuse or neglect, if five years have passed since the conviction.
• A drug-free workplace policy. Positive drug test results must be reported to the worker’s health regulatory board.

OLC publishes form OLC-3001-F for administrators’ mandatory reports about HCO and home health agency employees. The form is filed with the OLC Complaint Unit ⁠²⁷.

Clinical rules that shape your systems

These requirements in 12VAC5-381-300 through -360 determine how you set up intake, scheduling and charting:

• Every skilled service must be prescribed in a medical plan of care ⁠¹⁵. The plan must include diagnosis, prognosis, functional limitations, orders for the procedures and their frequency and duration, and medication and diet orders where applicable. The primary care physician must sign it and review it at least every 60 days.
• Verbal orders must be documented within 24 hours and countersigned by the prescriber. The physician must be told immediately of any change that calls for a new plan ⁠¹⁵.
• Supervision of nursing, therapy and personal care services happens as often as needed, but never more than 90 days apart ⁠⁸.
• Visit notes must be written on the day of service and filed in the client record within seven working days. Records are kept for at least five years after discharge. Records of minors are kept until five years after the client turns 18 ⁠⁸.
• You must keep posted business hours and provide or arrange on-call service 24 hours a day, seven days a week. You also need a written emergency plan for bad weather and disasters ⁠⁸.
• Drop sites for charting and supplies are allowed, but they may not have assigned staff, accept referrals or be advertised. If a drop site is used as a business office, it needs its own license ⁠⁸. A true branch office runs under your main license. VDH must add the branch address to the license within 10 business days of your notice ⁠³.

Policies to have written before you file

Under 12VAC5-381-180, the governing body must approve written policies that are reviewed at least once a year ⁠⁸. The 18 administrative topics include:

• admission and discharge criteria;
• informed consent;
• advance directives, including Durable Do Not Resuscitate Orders;
• client rights;
• contract services;
• medication management;
• mandated reporting of abuse, neglect and exploitation under § 63.2-1606;
• communicable diseases;
• record retention;
• emergency and on-call services;
• infection control;
• complaints;
• telemonitoring.

Separate financial and personnel policies are also required. These cover billing, refunds and collections, and job descriptions, credential checks, annual evaluations and background checks ⁠⁸.

Client-facing rules feed into the admission packet ⁠⁸:

• Before care starts, tell clients what Medicare, Medicaid or other third parties will pay and what they will owe.
• Give notice of fee changes within 30 days of learning about them.
• Give at least five days’ written notice before ending services.
• Give clients the complaint procedure, including contacts for your organization, the State Ombudsman and the OLC Complaint Unit.
• Propose a resolution to each complaint within 30 days.

Filing with OLC, in order

1. Request portal access

   VDH takes new HCO applications, renewals, exemption requests and license changes through the VDH OLC Portal. New applicants first request a user account as an “Applicant for Licensure” ⁠¹⁷.

2. Submit a complete application with the fee

   OLC treats an application as complete only when all requested information and the $1,500 fee are in. If anything is missing, OLC notifies you in writing ⁠¹¹. An incomplete application goes inactive six months after OLC receives it, and you then have to reapply and pay again ⁠¹¹.

3. File at least 60 days before your planned opening

   ⁠¹¹.

4. Take the prelicensure consultation

   OLC arranges it only after a complete application is on file. It covers the regulation and the survey process ⁠¹¹.

5. Inspection

   OLC may inspect an applicant’s activities and services before issuing or renewing a license ⁠³⁠¹¹. The Commissioner issues the license on finding compliance with the law and the rule ⁠³. The license is issued to a person and cannot be transferred. VDH may not license anyone sanctioned under 42 U.S.C. § 1320a-7b ⁠³⁠⁸.

The statute also lets the Commissioner refuse a license when Virginia has no reciprocal HCO licensing agreement with the state where the applicant lives or holds an HCO license ⁠³. Out-of-state owners should raise this with OLC early.

The rules do not set a deadline for OLC to decide an application. For questions, OLC’s forms list (804) 367-2104 and [email protected] ⁠²⁷.

Fees as published

Fees are due with the application and are not refundable ⁠¹². Changing the operator, organization name or address requires a reissued license. Give OLC 30 working days’ written notice of any such change ⁠⁸.

Inspections, changes and renewal

• Inspections. OLC makes unannounced on-site inspections as needed, and at least every two years. Inspectors may make home visits, which you arrange, and clients are told that agreeing to them is voluntary ⁠⁸.
• Plans of correction. After an inspection or complaint investigation, the administrator has 15 working days to submit a plan of correction. Corrections must be complete within 45 working days of the last day of the inspection ⁠⁸.
• Change notices. Give OLC 30 days’ notice before changing your service area, mailing address, ownership, services, operator, administrator or name, or before closing ⁠⁸.
• Closing. Give clients and OLC 30 days’ written notice before discontinuing services, and return the license within five working days after you stop operating ⁠⁸.
• Renewal. A license expires on the third anniversary of its issuance or renewal ⁠³. OLC makes renewal applications available at least 60 days before expiration. If you file a complete renewal on time, your license stays in effect until the new one is issued ⁠¹¹.
• Revocation and suspension. The Commissioner may revoke or suspend a license. VDH then notifies DMAS so that it can end or suspend your Medicaid provider agreement ⁠²⁴.

Getting paid by Virginia Medicaid

Virginia Medicaid pays through DMAS and its managed care organizations, and they pay only providers enrolled in DMAS’s Provider Services Solution (PRSS). Enrollment must match your provider type and specialty and show an active license ⁠²³. Since July 1, 2025, DMAS no longer gives a 90-day grace period after a license expires before it ends your enrollment. DMAS sends courtesy notices 90, 60 and 30 days before expiration ⁠²³. A late HCO renewal can therefore stop your Medicaid claims right away, so file your OLC renewal well before your expiration date.

Recent and pending changes

• Three-year licenses at $1,500. Section 32.1-162.9(E) makes HCO licenses expire on their third anniversary ⁠³. The rule sections on applications and fees, 12VAC5-381-40 and -70, were last amended effective May 22, 2025 ⁠¹¹⁠¹².
• Video supervision of aides. Section 32.1-162.12, last amended in the 2021 Special Session I, says VDH’s personal care rules must allow a licensed nurse to supervise home attendants by interactive audio or video technology ⁠²⁶. The administrative code text checked on October 12, 2026 still defines supervision as “face-to-face” guidance ⁠⁹. The sources do not say how OLC applies remote supervision in surveys, so ask OLC before you build a video-supervision model.
• Medicare moratorium. The nationwide freeze that began May 13, 2026 is the biggest variable for a new skilled agency’s timeline. Check the CMS moratoria page before you file a Medicare application ⁠²².

Sources

1. 1
   Virginia General Assembly, Code of Virginia § 32.1-162.7: Definitions (home care organizations) Checked 12 Oct 2026 · Back to text ↑
2. 2
   Virginia General Assembly, Code of Virginia § 32.1-162.8: Exemptions from article Checked 12 Oct 2026 · Back to text ↑
3. 3
   Virginia General Assembly, Code of Virginia § 32.1-162.9: Licenses required; renewal thereof Checked 12 Oct 2026 · Back to text ↑
4. 4
   Virginia General Assembly, Code of Virginia § 32.1-162.9:1: Barrier crimes; criminal records check; drug testing Checked 12 Oct 2026 · Back to text ↑
5. 5
   Virginia General Assembly, Code of Virginia § 32.1-162.11: Liability insurance required Checked 12 Oct 2026 · Back to text ↑
6. 6
   Virginia General Assembly, Code of Virginia § 32.1-162.15: Violation; penalties Checked 12 Oct 2026 · Back to text ↑
7. 7
   Virginia General Assembly, Code of Virginia § 32.1-162.15:1: Unlawful advertising as a home care organization Checked 12 Oct 2026 · Back to text ↑
8. 8
   Virginia General Assembly, Virginia Administrative Code, 12VAC5-381, Regulations for the Licensure of Home Care Organizations Checked 12 Oct 2026 · Back to text ↑
9. 9
   Virginia General Assembly, Virginia Administrative Code, 12VAC5-381-10: Definitions Checked 12 Oct 2026 · Back to text ↑
10. 10
    Virginia General Assembly, Virginia Administrative Code, 12VAC5-381-30: Exemption from licensure Checked 12 Oct 2026 · Back to text ↑
11. 11
    Virginia General Assembly, Virginia Administrative Code, 12VAC5-381-40: License application; initial and renewal Checked 12 Oct 2026 · Back to text ↑
12. 12
    Virginia General Assembly, Virginia Administrative Code, 12VAC5-381-70: Fees Checked 12 Oct 2026 · Back to text ↑
13. 13
    Virginia General Assembly, Virginia Administrative Code, 12VAC5-381-190: Financial controls Checked 12 Oct 2026 · Back to text ↑
14. 14
    Virginia General Assembly, Virginia Administrative Code, 12VAC5-381-210: Indemnity coverage Checked 12 Oct 2026 · Back to text ↑
15. 15
    Virginia General Assembly, Virginia Administrative Code, 12VAC5-381-300: Skilled services Checked 12 Oct 2026 · Back to text ↑
16. 16
    Virginia Department of Health, Office of Licensure and Certification, Home Care & Hospice Checked 12 Oct 2026 · Back to text ↑
17. 17
    Virginia Department of Health, Office of Licensure and Certification, Applications & Forms (VDH OLC Portal) Checked 12 Oct 2026 · Back to text ↑
18. 18
    Virginia Department of Health, Office of Licensure and Certification, The Accreditation Option for Deemed Medicare Status Checked 12 Oct 2026 · Back to text ↑
19. 19
    Virginia General Assembly, Code of Virginia § 32.1-102.1:3: Medical care facilities and projects for which a certificate is required Checked 12 Oct 2026 · Back to text ↑
20. 20
    Centers for Medicare & Medicaid Services, Federal Register, Announcement of Nationwide Temporary Moratoria on the Enrollment of Home Health Agencies and Hospices (2026-09717) Checked 12 Oct 2026 · Back to text ↑
21. 21
    Centers for Medicare & Medicaid Services, QSO-26-11: Nationwide enrollment moratorium for home health agencies and hospices Checked 12 Oct 2026 · Back to text ↑
22. 22
    Centers for Medicare & Medicaid Services, Provider Enrollment Moratoria Checked 12 Oct 2026 · Back to text ↑
23. 23
    Virginia Department of Medical Assistance Services, Updated Provider Enrollment Requirements, Effective July 1, 2025 Checked 12 Oct 2026 · Back to text ↑
24. 24
    Virginia General Assembly, Code of Virginia § 32.1-162.13: Revocation or suspension of license Checked 12 Oct 2026 · Back to text ↑
25. 25
    Virginia General Assembly, Code of Virginia § 32.1-162.10: Inspections; fees Checked 12 Oct 2026 · Back to text ↑
26. 26
    Virginia General Assembly, Code of Virginia § 32.1-162.12: Regulations Checked 12 Oct 2026 · Back to text ↑
27. 27
    Virginia Department of Health, Office of Licensure and Certification, OLC-3001-F: Mandatory Report of Home Care Organization, Home Health Agency, and Hospice Employees Checked 12 Oct 2026 · Back to text ↑
28. 28
    Centers for Medicare & Medicaid Services, State Operations Manual, Chapter 2: The Certification Process Checked 12 Oct 2026 · Back to text ↑

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