Washington home health agency license: the DOH in-home services license and certificate of need

One license, two routes

Washington does not issue a standalone home health license. DOH issues an in-home services agency license and approves service categories on it: home care, home health, hospice and hospice care center ⁠²⁴⁠³⁶. This guide covers the home health category. Agencies that only provide non-medical personal care or homemaker help need the home care category instead; see the Washington home care agency guide.

The first decision is not about forms. It is whether your agency will bill Medicare or Medicaid:

• State license only. RCW 70.127.080(2) says a certificate of need is not required for in-home services licensure, except to operate a hospice care center ⁠⁵. If you serve private-pay patients or other payers that do not require Medicare certification, the DOH license is the only state approval you need.
• Medicare or Medicaid agency. For certificate of need purposes, Washington defines a home health agency as an entity that “is, or has declared its intent to become, certified as a provider of home health services in the medicaid or medicare program” ⁠²⁶. Those agencies need certificate of need approval, and DOH tells licensed agencies to contact the Certificate of Need Program before applying for Medicare certification ⁠³⁰⁠³⁵.

You get the state license first either way. DOH states that “state licensure as a home health agency is a requirement for federal certification” ⁠³⁰.

What counts as home health, and who is exempt

A home health agency is “a person administering or providing two or more home health services directly or through a contract arrangement” in patients’ homes. A provider offering nursing services only may elect to be licensed as home health ⁠¹. The DOH application holds you to the two-service minimum: “You must choose at least two home health services in order to have an approved home health service category” ⁠³⁶. The services listed on the 2026 application form are skilled nursing, physical, occupational, respiratory and speech therapy, home health aide, IV services, durable medical equipment, nutritional counseling, medical social services and applied behavior analysis. A home health agency may also check non-medical services such as personal care, housework and meal preparation ⁠³⁶.

The license threshold is low. WAC 246-335-315 applies licensure to “any person who employs or contracts with two or more individuals” to provide in-home services ⁠¹⁰. Operating without a license is a misdemeanor, and each day counts as a separate violation ⁠². DOH may also fine an unlicensed operator up to $5,000 for each day ⁠⁹. You cannot put “home health,” “home health agency,” “visiting nurse services” or “home health services” in your business name or advertising until you hold the license ⁠³.

RCW 70.127.040 lists who is not regulated. The exemptions founders most often ask about ⁠⁴:

• nurses and therapists who work only as employees or contractors of a licensed agency
• family members providing care
• licensed facilities such as nursing homes, hospitals, adult family homes and assisted living facilities, when caring for their own residents
• case management that does not include direct care
• in-home assessments that do not lead to regular ongoing care at home
• Medicare-approved home dialysis programs and hospital at-home services under RCW 70.41.550

A nursing home or hospital that sends staff into homes as a home health agency is not exempt. It needs the in-home services license too ⁠².

The Medicare freeze since May 13, 2026

CMS imposed a six-month nationwide moratorium on Medicare enrollment of new home health agencies, branches and practice locations, effective May 13, 2026. New agencies are not enrolled unless the Medicare contractor received the enrollment application before that date ⁠³⁸. While the moratorium lasts, accreditation by a CMS-approved accrediting organization does not give a new agency deemed status ⁠³⁹. CMS can extend the moratorium in six-month increments ⁠⁴⁰. As of October 12, 2026, no notice extending or lifting it had been published.

This matters more in Washington than the Medicare numbers alone suggest. Apple Health (Medicaid) contracts for home health only with agencies that are “Title XVIII (Medicare)-certified,” licensed by DOH, signed to an HCA Core Provider Agreement and carrying a home health taxonomy ⁠³⁷. The billing guide’s only other route is a prior-authorized RN, and only where no home health agency exists in the client’s area and the RN cannot contract with a Medicare-certified agency ⁠³⁷. A Washington agency licensed during the freeze can serve private-pay patients and other payers that do not require Medicare certification. It cannot reach Medicare or fee-for-service Apple Health home health patients until it is certified.

Certificate of need for Medicare and Medicaid agencies

If you plan to certify, the certificate of need (CN) is the longest and most expensive step. It runs on its own track, separate from the license:

• Every county is a new agency. Under WAC 246-310-020, regular ongoing service in a county not already in your service area “shall be considered the development of a new home health agency” ⁠²⁷. A certified agency that wants another county applies to the CN program, not just to the licensing office ⁠¹⁴.
• Letter of intent first. For regular review, the letter must reach DOH at least 30 days before the application. It describes the services, estimated cost and service area, and it is valid for six months ⁠²⁸.
• Screening and review. DOH screens an application within 15 working days and returns it if you do not answer screening questions within 45 days. A regular review may last up to 90 days: a 45-day public comment period, then a decision within 45 days. Extensions are allowed ⁠²⁸. Competing applications for the same area go to concurrent review ⁠²⁸.
• Criteria. DOH decides on need, financial feasibility, structure and process of care, and cost containment (WAC 246-310-210 through -240) ⁠²⁸. Chapter 246-310 has a numeric need method for hospice (WAC 246-310-290) but none specific to home health ⁠²⁸.
• Fee. As published on 2026-10-12, the home health review fee is $24,666. DOH refunds 75% if you withdraw before review begins and half if you withdraw before the ex parte period ⁠²⁹.
• Validity. An approved CN is valid for two years, with one six-month extension ⁠²⁸.

The CN program offers optional technical assistance meetings and recommends them ⁠³⁵. Certified agencies also need CN program approval before DOH will approve a change of ownership ⁠¹³.

Before you apply: orientation class and key people

Orientation class. WAC 246-335-320(1) requires a DOH in-home services orientation class before you submit an application ⁠¹¹. DOH says applications without the certificate of completion will not be processed. The class is online, about four hours, free, and limited to 80 people. The remaining 2026 dates are November 4 and December 9, starting at 8:30 a.m. The certificate arrives by email within two business days and is valid for one year ⁠³¹. Existing licensees adding home health to a home care or hospice license do not take the class ⁠¹¹⁠³¹.

Administrator. You must name an administrator who is a home health employee and has the education and experience your own policies require. The administrator runs day-to-day operations and finances, supervises services across all approved counties, and designates an alternate in writing ⁠¹⁹. The rule sets no specific degree or license for this role.

Director of clinical services. You must employ a director of clinical services, who oversees nursing, therapy, nutritional and social services ⁠¹⁸⁠²³. The director must name a similarly qualified alternate in writing, complete at least 10 hours of training each year, and be available, personally or through a designee, during all hours patient care is provided ⁠²³.

Background checks. Both the administrator and the director of clinical services need a criminal history check processed through the Washington State Patrol and a DOH-approved disclosure statement. Both must be dated within three months of the application ⁠¹¹. Home health agencies run all staff checks through the Washington State Patrol. Home care agencies use DSHS’s Background Check Central Unit for hiring checks ⁠³².

The application package

DOH’s license requirements page and WAC 246-335-320 call for ⁠¹¹⁠³⁰:

1. Orientation certificate

   A copy of your certificate of completion.

2. Application and fee

   The in-home services application (DOH 505-051), mailed with a check or money order to Department of Health, P.O. Box 1099, Olympia, WA 98507-1099 ⁠³⁶.

3. Insurance

   Proof of commercial general liability coverage of $1 million per occurrence for bodily injury, property damage and contractual liability, or a $2 million combined single limit ⁠¹¹.

4. Background checks and disclosure statements

   for the administrator and director of clinical services.

5. Business licenses

   Every government business license for each office location, including state, county or city licenses ⁠³⁰.

6. FTE worksheet

   Your anticipated full-time equivalents at start-up. The worksheet in the April 2026 packet (dated June 2021) says at least one FTE per service area per service category ⁠³⁶, but WAC 246-335-990 has assumed a minimum of 2 for renewal fees since June 1, 2026 ⁠²⁴; ask DOH which figure it expects at start-up.

7. Organization and supervision

   An organizational chart or narrative, plus a description of how you will manage and supervise home health services in every county you request ⁠³⁰.

8. Services list

   The services you will provide directly and those under contract ⁠⁵⁠³⁰.

9. Policies and procedures

   covering the rule chapter. Home health policies may cite Medicare or accreditation standards only if you are already Medicare certified or accredited ⁠¹¹. A new private-pay agency must write to the state rules.

The statute also requires you to identify officers, partners, managing employees and anyone owning 10% or more of the applicant ⁠⁵. You must keep at least one in-state office where records are kept ⁠¹⁴.

Fees as published

All in-home services fees are in WAC 246-335-990. The current version was adopted February 3, 2026 and took effect June 1, 2026 ⁠²⁴⁠²⁵.

The 24-month home health renewal fee depends on your FTEs. DOH assumes at least 2 FTEs for each approved county per service category ⁠²⁴. Table 2 applies only to agencies that are Medicare certified or accredited by a DOH-recognized organization and meet the substantial equivalency requirements ⁠²⁴.

The June 2026 change raised the initial fee from $3,283 to $5,000. The smallest home health renewal rose from $3,283 to $5,100, and the minimum assumed FTE count went from 1 to 2. The rule also dropped the old rule that charged 75% of the renewal fee for each additional service category on a multi-category license ⁠²⁵. An agency adding home care to a new home health license now pays a second $5,000 ⁠²⁴.

If you withdraw before any survey or technical assistance, DOH refunds two-thirds of the fees, less $50. After a survey, it refunds one-third, less $50. Nothing is refunded after more than one on-site visit, or once nine months have passed without a license ⁠²⁴.

Counties and service areas

You list the counties you want on the application, and DOH must approve each one before you provide services there. DOH says approval of a county carries “the expectation that agencies will strive to service all clients or patients within the county boundaries” ⁠³⁶. The first county is included in the license fee. Each additional county adds the surcharge in the fee table ⁠²⁴. The surcharge rule does not say which counties are urban and which are rural, so confirm the classification with DOH when you file.

DOH’s criteria for approving a service area may not limit the number or type of agencies in a county ⁠⁵. That is the difference from the CN process, which is a need test. To add counties later, a private-pay agency files an amended application and waits for approval before serving the new county ⁠¹⁴. A Medicare-certified agency also goes through the CN program ⁠¹⁴. For Medicare agencies, the application asks you to check both your state counties and the counties authorized by your certificate of need ⁠³⁶.

The initial survey and the nine-month clock

After DOH accepts your application, its Office of Investigation and Inspection schedules an initial survey, and “applicants must pass the survey process in order for their license to be issued” ⁠³⁰. The survey is announced ⁠¹¹. The surveyors are registered nurses. Initial surveys focus on your policies and procedures, sample employee and patient files, and your knowledge of the rules ⁠³³. DOH publishes the home health checklists its surveyors use, covering deficiencies, policies, the bill of rights and personnel files, on its survey program page ⁠³³.

The clock starts when you submit. Under WAC 246-335-320(4), you have nine months to complete every step, and DOH may close the application with no refund after that. You may reapply with new fees ⁠¹¹. DOH has not published a standard processing time for the license.

Medicare certification or accreditation does not replace the initial state survey for a new applicant ⁠¹⁷. Exemption from routine state surveys comes later, through substantial equivalency ⁠⁶⁠¹⁷.

What surveyors check once you operate

Part 3 of WAC 246-335 (sections 505 to 560) holds the home health operating standards. These are the Washington-specific points that shape staffing and workflow:

• Start of care. Services must start within seven calendar days of accepting a physician or practitioner referral. Documented exceptions are a request from the practitioner or patient, or trouble reaching the patient ⁠²⁰.
• Discharge. Patients get at least 48 hours’ notice, except for worker safety, significant noncompliance or nonpayment ⁠²⁰.
• Who signs orders. Physicians, podiatric physicians, physician assistants and ARNPs can authorize a plan of care ⁠¹⁸.
• Plan of care reviews. Acute patients every two months, maintenance patients every six months, and equipment-assessment or aide-only patients every twelve months. Signed plans must come back within 60 days ⁠²². Aide-only patients may have a shorter plan of care with no practitioner signature ⁠²².
• Aide supervision. Monthly for acute patients and every six months for maintenance or aide-only patients. Visits may be on-site or by telemedicine, and audio-only visits are allowed only with an established relationship ⁠²³.
• Home health aides. An aide must be a nursing assistant certified (NA-C) or registered (NA-R) ⁠¹⁸. A registered aide must become certified within 12 months of hire or stop providing patient care ⁠²¹. Aides must complete the DSHS nurse delegation class before taking part in delegation, and delegation is limited to stable, predictable patients ⁠²⁰.
• Personnel files. WSP background checks renewed every two years, a written character, competence and suitability determination for any non-disqualifying record, in-person orientation with skills verification, CPR with hands-on skills observed by a certified trainer, and annual evaluations that include on-site observation of care ⁠²¹.
• Infection control. A TB risk assessment on DOH’s form at hire and every year. If staff face exposure risk, you must offer the Hepatitis B vaccine series at the agency’s expense ⁠²¹.
• Plan of operation. This must include an emergency preparedness plan for disasters and public health emergencies, and a process for referring patients elsewhere if you close ⁠¹⁹.
• Mandatory reporting. Staff must report rule violations to DOH within 14 calendar days. They must report suspected abuse, neglect, abandonment or financial exploitation to DSHS and law enforcement immediately ⁠²¹.

Renewal, ownership changes and enforcement

The first license lasts 12 months, and each renewal lasts two years ⁠⁷. File the renewal at least 30 days before expiration, with proof of insurance, a new FTE worksheet, current background checks for key staff and the fee ⁠¹². The late fee starts counting from that 30-day mark ⁠²⁴.

DOH may survey you unannounced at any time, and at least once per license period ⁠¹⁵. Agencies that are Medicare certified, or accredited by a DOH-approved organization, can skip routine state surveys if they had an on-site survey in the previous 24 months and send DOH the findings ⁠⁶⁠¹⁷. DOH may still run validation surveys and investigate complaints ⁠⁶⁠¹⁷. After a survey, for deficiencies DOH judges not significant, broadly systemic or recurring, you have ten working days to submit a plan of correction and 60 days to finish the corrections. For more serious findings DOH can issue a directed plan of correction instead ⁠¹⁶.

You must notify DOH within 30 days of a new administrator or director of clinical services, an office opening or closing, or a smaller service area ⁠¹⁴. For a change of ownership, the current licensee and the buyer must each file at least 30 days ahead, and the buyer pays $500 per service category ⁠¹³⁠²⁴. A license cannot be transferred without DOH approval ⁠⁷. If DOH finds a repeat of a violation it has already cited, it can fine you up to $3,000 per violation ⁠⁸.

Rule changes in 2025 and 2026

• Fees (in effect). WSR 26-04-110 raised initial, renewal and survey fees on June 1, 2026, as shown above ⁠²⁵.
• Audio-only telemedicine (adopted). DOH amended the home health definitions to allow audio-only telemedicine under Senate Bill 5821 (WSR 25-21-127) ⁠³⁴. The amended definitions took effect November 21, 2025 ⁠¹⁸. Audio-only supervisory visits are allowed only for patients with an established relationship, meaning an in-person appointment with the agency provider within the past three years or a referral from a provider who had one ⁠¹⁸⁠²³.
• Uniform enforcement tool (pending). DOH filed a CR-101 (WSR 25-17-068) to amend in-home services enforcement rules under ESSB 5271 ⁠³⁴. No proposed rule text was posted on DOH’s rules page as of October 12, 2026.
• Federal. The CMS home health enrollment moratorium that began May 13, 2026 is the main limit on new Washington agencies that want Medicare or Apple Health patients ⁠³⁸.

For the full list of Washington care licenses, see the Washington state page. To compare home health licensing across states, see home health agency licenses.

Sources

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