How to start a home care agency in Maryland (RSA license, 2026)

The statute defines the business: "“Residential service agency” means any person that is engaged in a nongovernmental business of employing or contracting with individuals to provide home health care for compensation to an unrelated sick or disabled individual in the residence of that individual." (Health-General §19-4A-01(f)(1)). COMAR adds that one service is enough: a business giving "at least one home health care service" for pay is an RSA (COMAR 10.07.05.02B(25)(a)(i)).

Eleven services count as home health care, among them home health aide, nursing, the therapies, drug services, medical social services and home medical equipment (Health-General §19-4A-01(b)). The application lists ten service boxes and has no separate box for personal care or companionship (application, Section B). By our reading, a personal care agency ticks home health aide, and usually nursing for the RN’s work. On OHCQ’s October 2026 list, every RSA that lists home health aide services also lists nursing (OHCQ RSA list, our count).

OHCQ describes the work this way: "Some agencies have nurses that provide skilled nursing care and certified caregivers that provide assistance with activities of daily living, such as bathing, grooming, and dressing." (OHCQ, Residential Service Agencies). Activities of daily living are eating or being fed; grooming, bathing and oral hygiene; mobility, transferring, ambulation and access to the outdoors; toileting; and dressing (COMAR 10.07.05.02B(1)).

Before the license. "A person may not operate, attempt to operate, or hold one’s self out as operating a residential service agency, unless the person is licensed under this subtitle." (Health-General §19-4A-07). Operating without a license can bring a civil money penalty of up to $10,000 per violation, and it is a misdemeanor (COMAR 10.07.05.27).

Three OHCQ licenses are easy to confuse. Most new personal care businesses need the first.

Employing caregivers makes you an RSA. A referral agency is outside the RSA definition only if screening or referring for the client’s selection is "its sole business operation, and does not itself provide any home health care service" (COMAR 10.07.05.02B(25)(b)(vi)).

An aide RSA cannot add therapy. OHCQ says "an RSA that provides assistance with activities of daily living through nursing and home health aide services may not also provide other home health care services, including therapy services, under that license" (OHCQ discharge inservice, slide 11). An RSA may provide only the services it is approved for, and adding one needs a new application with policies for it (COMAR 10.07.05.05A).

Advertising. An RSA may not advertise that it is licensed as a hospice, home health agency or nursing referral service agency unless it holds that license too (COMAR 10.07.05.06B).

Maryland’s license is nurse-supervised. The rule says: "For clients who require skilled services or assistance with the activities of daily living, an agency shall have a registered nurse to provide oversight for" implementation of the care plan, delegation, supervision and training (COMAR 10.07.05.12E(1)). The rules do not say whether the nurse must be an employee or may work under contract.

Clients who need no hands-on help

The RN oversight rule is tied to clients who need skilled services or help with activities of daily living. But the record for a client "assessed as not requiring certified caregivers or skilled services" still includes a nursing assessment, a plan of care, the services provided and any significant change (COMAR 10.07.05.14B). By our reading, every client of a licensed RSA gets a nursing assessment, even one who receives only household help. Ask OHCQ how it reads this.

Certified and uncertified caregivers

The agency must provide or refer a certified caregiver to a client who needs one for activities of daily living, or who needs medication administration (COMAR 10.07.05.10E). An uncertified caregiver may serve a client who:

• does not need help with activities of daily living;
• "only requires assistance with activities of daily living and in the judgment of the supervising nurse, there are no predictable adverse health consequences"; or
• signs a waiver of skilled services (COMAR 10.07.05.10D).

The Board of Nursing’s delegation rule matches the second case: "An unlicensed individual merely provides assistance with activities of daily living unless the client’s needs are such that adverse health consequences are predictable." (COMAR 10.27.11.05E(2)). Only a cognitively capable adult client, not a representative, may waive the agency’s recommendation of certified care for help with routine treatments or self-administration of medication, after a documented discussion of risks and benefits on a signed informed consent form (COMAR 10.07.05.12D).

Certified nursing assistants and medication technicians must be certified by the Board of Nursing before they practise (Health Occupations §8-6A-02(a)), and the agency verifies current certification when it screens them (COMAR 10.07.05.10B(1)(b)). The Board’s rules now name two nursing assistant certificates, CNA-I and CNA-II (COMAR 10.39.01.02B).

Medication

• Administration is nursing. "Administration of medication is a nursing function. As such, the nurse retains full responsibility for medication administration." (COMAR 10.27.11.05F) The Board’s rule sets which medications and routes a nurse may delegate to certified medication technicians and certified medicine aides, and in which settings (COMAR 10.27.11.05H). Ask your RN to confirm how that applies in clients’ homes.
• If staff administer. Licensed or certified staff, consistent with Maryland law and the plan of care unless the client has signed an informed consent form under .12D, only as the physician orders, with medications, errors and adverse reactions recorded (COMAR 10.07.05.12F). The RN then supervises on site at least every 45 days.
• Help with self-administration. A client signs an informed consent form agreeing to help from a nonlicensed person with routine treatments or self-administration of medication (COMAR 10.07.05.08B(1)(d)(ii)).
• OHCQ’s training limits. OHCQ’s outside trainer checklist says aides without RN-supervised medication management must never administer medications but may remind clients who take their own, and "CMTs/CMAs may not calculate medication doses or fill pill boxes" (OHCQ trainer checklist).

Reporting a caregiver. If the agency knows of conduct by a caregiver it provided or referred that may be grounds for Board of Nursing action, "the agency shall report the action or condition to the Board of Nursing and the Office of Health Care Quality immediately when the action or condition is known by the agency" (COMAR 10.07.05.10F).

COMAR 10.07.05.08B(1) begins "An agency shall develop and implement policies and procedures, including but not limited to" and lists 23 items in five groups (COMAR 10.07.05.08B(1)). Copies of these policies are part of the application (COMAR 10.07.05.04A(2)(i)).

The index. Section B of OHCQ’s application lists the same 23 items in the same order. For each one you "list the name of the attached document that includes the specific policy or procedure, as well as the page numbers", or enter N/A where you ask for a waiver (application, Section B).

Waivers. "The Department may waive the requirement of a policy and procedure that is required in §B of this regulation upon the agency’s written explanation as to why the policy and procedure is inappropriate or unnecessary to the agency’s specific operation" (COMAR 10.07.05.08B(2)). The application has a field for the request, where you list the policy and explain why it is inappropriate or unnecessary for your agency (application, Section B). Our example: enteral and parenteral nutrition at an agency that offers neither. OHCQ does not publish which waivers it usually grants.

Written duties outside the 23

Other rules add screening policies (.10A), an internal complaint process (.09A), a 24/7 on-call procedure given to clients in writing (.12G), communication of changes in condition (.14C), record completion and safeguards (.15D) and client rights policies (.16A). (COMAR 10.07.05.09A, .10A, .12G, .14C, .15D, .16A) The governing authority also meets management at least once a year to review and advise the agency on policies, and keeps minutes of who attended, the agenda and the actions taken (COMAR 10.07.05.08A).

Format

OHCQ’s 2018 application instructions, now archived, suggested a format for each policy: the date the governing body approved it, the title, a policy statement, its purpose, and procedures saying who does what, when and where (OHCQ instructions, 2018). The current application does not repeat it. Nothing we saved stops a policy starting from a template. The rule says an agency shall develop and implement its policies, so our suggestion is to write procedures that match how your agency actually works.

Where the sources are silent

• How OHCQ reviews the policies. The current application and RSA page do not say how many rounds of revisions OHCQ allows. Its 2020 slides said it could deny an application "After 3 unacceptable reviews of revised policies and procedures" (OHCQ slides, 2020), which is old guidance.
• Incident reporting. We found no general rule telling an RSA which incidents to report to OHCQ. The rules do require complaint investigations, Board of Nursing reports and abuse reports (below).
• Liability insurance. The application asks for workers’ compensation proof; we found no liability insurance rule for RSAs.
• Administrator. The rules set no qualifications for an agency administrator or manager. The application asks for a primary and a secondary contact.

1. The application and five attachments

"Submit the licensure application and all supporting documents to OHCQ through the Submit a License Application." (OHCQ, RSA page) "The application must be typed. Handwritten applications are not accepted and will be returned to the applicant." (application) The attachments:

1. Business plan: a 1-year operating budget, a marketing plan that identifies the populations to be served, and a detailed and specific description of services (COMAR 10.07.05.04A(2)(h)).
2. Organizational chart.
3. Policies and procedures as specified in COMAR 10.07.05.08B, indexed in Section B (above).
4. SDAT letter of good standing, ordered from Business Express (attachment 4).
5. Workers’ compensation: the declaration page, or a Certificate of Compliance (corporations and LLCs not required to carry cover) or a Letter of Exemption (sole proprietors and partnerships with no employees) (attachment 5).

The form also asks for your business hours, the services you will provide, whether you will supply invasive medical equipment, whether you serve adults, children or both, any branch offices, ownership (the rule asks for owners of 25% or more; the corporation section asks for every owner or investor of 2% or more), and eight disclosures, such as prior license actions, criminal convictions and findings of Medicare or Medicaid violations (COMAR 10.07.05.04A(2)(d); .04A(2)(c), (g)). An owner, member, partner or officer signs the attestation and swears to being at least 21 (.04A(2)(b)). Someone whose license the Department suspended or revoked may not own, operate or manage another agency for 10 years without good cause shown (.04B(1)).

2. The worker classification certification

The statute makes it a condition of the license: "As a condition of obtaining an initial license from the Department to operate as a residential service agency and every 3 years thereafter", someone with authority over the agency’s pay or employment practices certifies to the Department on its form (Health-General §19-4A-11(b)). OHCQ says the person reads the Attorney General’s Guidance Document and completes the RSA Certification online (OHCQ, RSA page), and "This is a requirement for all RSA applicants, including those that do not plan to hire personal care aides." (application)

3. OHCQ’s review

The Department reviews every application to decide whether the applicant can provide appropriate services to sick or disabled people at home and meets COMAR 10.07.05 (COMAR 10.07.05.04C). "Before approving or denying an application for licensure, the Department may conduct an announced or unannounced on-site inspection of the agency." (.04D) If the agency is not compliant and more than one prelicensure visit is needed, the rule text lets the Department charge $250 for each extra visit (we could not confirm it is still charged since 2018) or deny the license (.04K).

The result is approval, with or without conditions (such as an approved management firm or a license term under 1 year), or denial with a letter explaining the reasons and appeal rights (.04E; application). "OHCQ will hold an application for 180 days from the date of initial receipt, after which the application will be deemed inactive and administratively closed." (application)

4. A provisional license and a first survey? (2020 guidance, unconfirmed)

The rule still allows a provisional license where "the agency intends to provide services limited to skilled nursing and home health aid services", and a provisional license cannot be extended (COMAR 10.07.05.04J). In 2020, OHCQ’s initial license slides for agencies offering skilled nursing with aides described how that worked:

• After the approval letter, a 90-day provisional license: put the policies into practice, market for three clients, hire staff, and send a signed Statement of Readiness with the signed RN contract, staff list and organizational chart (slides 53-56).
• "Within 45 days, you must admit 3 patients who will receive at least 6 visits each of skilled nursing or aide services"; then an OHCQ nurse surveyor makes an unannounced on-site survey (slide 56).
• The survey covered written policies and procedures; clinical record management; personnel files; client rights information; internal complaint records; clinical records; staff interviews; home visits or phone interviews with clients; quality assurance documents (slide 59).
• Findings went in a Statement of Deficiencies, and an acceptable Plan of Correction came before the license (slide 60).

Those slides are no longer on OHCQ’s site (we cite an Internet Archive copy), and the current application and RSA page do not describe this process. We could not confirm it for 2026. If it still applies, your forms (assessment, care plan, RN supervision record, consent and waiver forms, on-call log, complaint report) matter as much at the survey as your policies did at application. Ask the RSA Team what to expect after approval.

5. After licensing

• Post and advertise. Display the license "in a conspicuous place, at or near the entrance of the agency’s office" (COMAR 10.07.05.03D). All advertising and marketing shows your license number and the statement “Licensed as a residential service agency by the Maryland Department of Health, Office of Health Care Quality” (.06A).
• Inspections. OHCQ "may conduct announced or unannounced licensure inspections or complaint investigations to ensure compliance with the requirements of this chapter", and the agency is open for inspection during all the business hours on its application (.07A). OHCQ’s 2019 overview says complaint investigations are unannounced on-site surveys with record reviews and interviews (OHCQ, complaint survey process).
• Plans of correction. After a notice of violation, an acceptable plan of correction within 10 calendar days, with a completion date for each deficiency; you may ask for an informal dispute resolution conference within 10 days (.07E-F). Civil money penalties can reach $10,000 per instance or $1,000 per day (.22).
• Changes. Tell the Department immediately of any change to the information in your latest application (.05C). A name or address change needs an amended license; the rule text says $50, and we could not confirm it is still charged (.05A(3)). A branch office with the same owner tax ID, upper management, policies and service area may operate under your license (.02B(3), .03C(2)).
• Closing or selling. Give the Department written notice at least 45 days before voluntarily closing, changing ownership or selling, with how clients will be told and helped; tell clients in writing 45 days before. A new owner applies for a new license at least 45 days before the transfer. (.05B) A stock transfer that changes who controls the agency, or of more than 25% of the stock, counts as a sale (.05A(4)(b)).
• Telling clients about license actions within at least 30 days: a significant change in licensure status, a voluntary surrender, or a denial, revocation or suspension (.26).

For criminal history checks, an RSA is an adult dependent care program (Health-General §19-1901(b)(6)). "Before an eligible employee may begin work for an adult dependent care program, each adult dependent care program shall, for each eligible employee":

• A criminal history check. Apply for a State criminal history records check through the Criminal Justice Information System (CJIS) Central Repository, or have a licensed private agency run a background check (§19-1902(a)(1)). A private agency check covers every state where you know or have reason to know the worker worked or lived in the past 7 years (§19-1902(d)), and the federal Fair Credit Reporting Act applies (§19-1906).
• A reference from the most recent employer, which "shall, at a minimum, seek information about any history of physical abuse on the part of the potential employee" (§19-1902(b)).
• Confidential results. "Information obtained from the Department or a private agency under this subtitle shall be maintained in a manner to insure the security of the information." (§19-1907)

The CJIS route. Get an authorization number first; "There is no fee required to become an authorized agency to receive criminal background information." (DPSCS). Fingerprints are taken at a designated law enforcement agency or an approved provider, with photo ID. A worker who returns to the same program need not be fingerprinted again if the program kept them on the Central Repository’s list (COMAR 12.15.03.03). DPSCS says in-state employment checks must be fingerprinted electronically by live scan; ink cards are accepted only for a bona fide medical reason. The State-only check costs $38 in person at the Central Repository, including its $20 service fee; approved private fingerprinting providers may charge their own service fee. Those are DPSCS fees, not CareRulebook prices (DPSCS fee schedule). DPSCS publishes no processing time for live scan employment checks.

Who the statute covers. An eligible employee works for pay with routine, direct access to clients and "is not licensed or certified under the Health Occupations Article" (Health-General §19-1901(h)), so certified nursing assistants and nurses fall outside it. But COMAR’s screening list applies to every employee, independent contractor and contractual employee who will serve clients (COMAR 10.07.05.10A). By our reading, the safe course is to run the criminal history check for everyone, certified or not. Ask OHCQ if you plan otherwise.

The nine screening steps in COMAR

State criminal history records check or private agency background check; license or certificate verification; basic health screening including TB; references; employment history; I-9; identity and work eligibility; in-person interview before referral; skills assessment and demonstration before referral. (COMAR 10.07.05.10B(1)) Screening and training records for each worker are kept at the agency’s business office (.10B(2), C). If you subcontract with another licensed agency, that agency verifies the screening and gives you evidence of it (.10H). OHCQ’s FY 2018 list of most cited RSA rules was led by .10, this screening regulation (OHCQ slides, 2020, slide 21).

We found no abuse registry check named in the RSA rules or the criminal history statute.

The agency ensures that the people it refers are trained for the care its clients need (COMAR 10.07.05.11A). "At a minimum, training for individuals providing care in clients’ homes shall include" (COMAR 10.07.05.11C):

1. Instruction and supervised practice in relevant personal care services of the sick or disabled at home.
2. Identifying situations that need referral to a registered nurse, including significant changes in a client’s condition.
3. Record keeping.
4. Ethical behavior and confidentiality of information.
5. CPR.
6. Standard precautions for infection control.
7. Prevention of abuse and neglect.

The rule sets no hours for these topics. You may train your own staff; "If an outside trainer is used, that individual must have OHCQ’s approval prior to training." (OHCQ, RSA page). Each worker also completes a skills assessment and demonstration before referral to clients (COMAR 10.07.05.10B(1)(i)), and the RN takes part in training and retraining (.12B(2)(c)).

Dementia training (statute)

• Within 45 days of starting, each member of the direct care or supervisory staff gets at least 3 hours of online or in-person dementia training covering an overview of Alzheimer’s disease and dementia, person-centered care, the assessment and care planning process, activities of daily living, and dementia-related behaviors and communication (Health-General §19-4A-03.1(c)(1)(i)).
• Every calendar year, each member of the direct care or supervisory staff "receives 2 hours of online or in–person continuing education training regarding Alzheimer’s disease and dementia each calendar year" (§19-4A-03.1(c)(1)(ii)).
• Exemption. The initial 3 hours are not needed for someone with 24 consecutive months of dementia care experience who holds a completion certificate; the yearly 2 hours are not needed if done in the past 12 months. (§19-4A-03.1(d))
• Certificates and records. Whoever gives the training issues a certificate of completion; the RSA keeps records of the type of training each person received. The training may be given by the supervisory staff member who develops plans of care. (§19-4A-03.1(c)(2), (e)-(f))

The duty came from Chapter 487 of 2021 and has applied since July 1, 2022 (Chapter 487 of 2021). It is in the statute, not in COMAR 10.07.05, but OHCQ’s outside trainer checklist already checks it (OHCQ trainer checklist, item 9). It does not apply to an RSA that only provides durable medical equipment (§19-4A-03.1(b)).

OHCQ’s trainer checklist also marks CPR with a hands-on component every 2 years, an emergency preparedness plan, and training within 45 days of hire, yearly and before client referral, "26 Reg Update": signalled, not proposed. None of these is rule text yet (Rule changes).

• The clinical record. Kept securely and confidentially for each client, with any current orders, the nurse’s assessment, the care plan, medications administered or taken, allergies, nutritional needs, supplies and equipment, care notes, contact details for physicians and the client representative, and discharge documents (COMAR 10.07.05.14A).
• Care notes at least weekly. Staff write care notes on admission and at least weekly, on any significant change and when the care plan changes; notes are detailed, legible, dated and signed with name and title. (.14D)
• Changes in condition. Policies so that changes in a client’s condition or preferences are documented and told in a timely manner to the client, the representative where appropriate, and the care team (.14C).
• Client representatives. The agency recognizes guardians, advance directive agents, surrogate decision makers, powers of attorney, representative payees and documented designees, within their authority, and records who holds it (.13).
• Retention. "The agency shall maintain a client’s record for 5 years after the client is discharged." For a client under 18, until age 21 or 5 years after the record is made, whichever is later (.15A). Records of discharged clients are completed within 30 days (.15D(1)).
• What stays at the office. Files on current clients, clients discharged in the last 12 months, current staff, staff who left in the last year and quality assurance activities are kept on site; other records may be off site if available within 24 hours. (.07C(2))
• 24/7 on-call. Clients can reach the agency 24/7; an appropriate person responds within 1 hour (sooner if medically needed); inquiries are logged; clients get written on-call procedures and the number. (.12G)

What clients are told

Written policies on client rights and responsibilities make sure each client gets: a cost estimate; costs the client pays if not covered; itemized bills on request; caregiver names; supervisor’s name and contact; the 24/7 number; any subcontracting (COMAR 10.07.05.16C). Clients also get information about advance directives (.16E), and may "accept or reject, at the client’s or client representative’s discretion without fear of retaliation from the agency, any employee, independent contractor, or contractual employee that is referred by the agency" (.16H).

Rights include dignity; adequate, lawful care; joining care planning; refusing treatment; privacy; freedom from abuse, neglect, involuntary seclusion and exploitation; confidentiality; complaining without retaliation; access to OHCQ, APS and CPS complaint routes (.16D).

Complaints

An internal complaint process with notice to clients, investigation protocols and timely investigation of written complaints without disrupting services; each investigation report records the time, date, place and people involved, the complaint, its disposition and follow-up (COMAR 10.07.05.09). Clients get OHCQ’s hotline: "The RSA Hotline number is (800) 492-6005." (OHCQ, RSA page). OHCQ sends billing complaints to the Attorney General’s Consumer Protection Division (OHCQ, File a Complaint).

Abuse, neglect and exploitation

• Adults. Health practitioners, police and human service workers (any professional employee of a public or private health or social services agency or provider) who contact or attend a vulnerable adult and suspect abuse, neglect, self-neglect or exploitation must report to the local department of social services as soon as possible. Anyone else may report. (Family Law §14-302; §14-101(h)) Whether an aide counts as a human service worker is not settled in what we saved. By our reading, the safe course is a policy that every staff member reports.
• Children. Health practitioners, educators, human service workers and police must report suspected child abuse or neglect orally at once and in writing within 48 hours; everyone else must also notify the local department or police. (DHS; Family Law §§5-704, 5-705)
• The hotline. "Report adult or child abuse or neglect at 1-800-91Prevent (1-800-917-7383)" (Maryland Department of Human Services)
• The Board of Nursing and OHCQ, immediately, for caregiver conduct that may be grounds for Board action (COMAR 10.07.05.10F).

The fee the rule still prints. COMAR 10.07.05.04A(2)(k) still asks for "a nonrefundable license fee of $1,000 made payable to the Department for a 3-year licensing fee" (COMAR 10.07.05.04A(2)(k)). Chapter 661 of 2018 struck from the statute the requirement that the Secretary charge RSA licensing fees (Chapter 661 of 2018). Its fiscal note says the bill "effectively authorizes OHCQ to issue nonexpiring licenses to specified provider types and eliminate all related licensing fees" (fiscal note, SB 108 (2018)). COMAR 10.07.05 has not been amended since March 13, 2017 (COMAR 10.07.05, history). OHCQ’s current application says there is no fee. By our reading, you pay nothing to apply.

Renewal: our reading. COMAR 10.07.05.04H-I still describe a 3-year license with a renewal application. After Chapter 661 of 2018 the statute no longer provides for renewal, and OHCQ’s RSA page has no renewal process. By our reading licenses no longer expire, but the 3-yearly worker classification certification still applies. Confirm with OHCQ. (COMAR 10.07.05.04H; Chapter 661 of 2018) The 2018 fiscal note showed the fee before then as $1,000 for initial and renewal licenses on a 3-year term, for 1,139 RSAs (fiscal note, Appendix 2).

Other costs. Workers’ compensation cover, the registered nurse’s time, dementia and other training, and the SDAT letter of good standing. The rules set no liability insurance minimum and we found no liability insurance rule. DPSCS offers full State and FBI checks to authorized agencies only; private employers approved through its Private Party Petition get Maryland records only. Where a full check is run, the FBI’s part of the fee rose from $12 to $15 on October 1, 2026, so DPSCS says to add $3 for those checks (DPSCS).

Timeline. OHCQ’s 2018 application instructions said processing should take 2 to 3 months after all documents arrive. No current figure is published for RSAs. (OHCQ says NRSA licenses generally take 1-2 months.) (OHCQ instructions, 2018; OHCQ, NRSA page) We cannot give you a date.

OHCQ’s RSA spreadsheet dated October 2, 2026 has 3,080 rows and 3,065 distinct license numbers. 2,542 rows list home health aide services, and every one of those also lists nursing; 321 list durable medical equipment only. The largest jurisdictions are Prince George’s County (830), Baltimore County (740) and Montgomery County (407) (OHCQ RSA list, our count).

The Department of Legislative Services counted 2,986 licensed RSAs on March 2, 2026 (fiscal note, HB 1284 (2026)), against 1,139 in OHCQ’s July 1, 2016 provider census, used in the 2018 fiscal note (fiscal note, SB 108 (2018)). Hospital and nursing home discharge planners are told to check that a chosen RSA is licensed for the services in the discharge plan (OHCQ transmittal, March 24, 2026).