How to start a home care agency in New York (the LHCSA license, 2026)

The statute covers any home care services agency that provides nursing, home health aide or personal care services, "directly or through contract arrangement" (PHL s. 3605(1)). The rule adds advanced home health aide services and says no agency may provide any of them "unless it has been approved by the Public Health and Health Planning Council and has been issued a license" (10 NYCRR 765-2.1(a)).

• Personal care. "Personal care services shall mean assistance to the patient with personal hygiene, dressing, feeding and household tasks essential to his/her health." (10 NYCRR 700.2(c)(16)) This is most private-pay home care.
• Housekeeper (chore) services. "Housekeeper services shall mean the provision of light work or household tasks which do not require the services of a trained homemaker." (10 NYCRR 700.2(c)(19)) These are not in the license trigger.
• Homemaker services: the gray area. "Homemaker services shall mean assistance and instruction in managing and maintaining a household, dressing, feeding and incidental household tasks for persons at home because of illness, incapacity or the absence of a caretaker relative." (10 NYCRR 700.2(c)(18)) Homemaker services are not in the trigger either, but they include dressing and feeding, which also appear in the definition of personal care.

Our reading: a business that offers only housekeeping, errands or companionship, with no hands-on help, probably needs no LHCSA license. No rule we found mentions companion care. Any help with hygiene, dressing or feeding puts you at or over the line. DOH has not confirmed this; ask the Bureau of Home Care Licensure and Certification before you start.

How DOH decides you are an agency

"The following criteria shall be used to determine whether an organization or group of individuals are subject to licensure as a home care services agency": who is accountable for admission and discharge decisions, for providing or arranging care, for care standards and policies, and for setting charges; the employment relationship of the staff; and the scope of services (10 NYCRR 765-2.1(d)).

Who is exempt

Exempt: certified home health agencies, long term home health care programs, AIDS home care programs and hospices; agencies serving only people in a program run or regulated by another State agency; licensed nurses’ registries; sole-practitioner nurses; dialysis facilities for home dialysis (10 NYCRR 765-2.1(c)). Consumer directed personal assistance (CDPAS) now runs through one statewide fiscal intermediary, PPL, since April 1, 2025 (DAL DHCBS 25-02), so by our reading it is not a route into the market for a new business.

Before the license. New applicants sign this: "The applicant is aware that they may not commence operation of the home care agency until after the application has been approved by the Public Health and Health Planning Council and the agency has obtained a license from the Department of Health." (DOH application, Section F).

New York has limited new home care agencies since 2018, first with a moratorium and then with a need test. The 2018 budget stopped new LHCSA licensing until March 31, 2020: "The moratorium on the licensure of Licensed Home Care Services Agencies (LHCSAs) pursuant to Part B of Chapter 57 of the Laws of 2018 expired on March 31, 2020." (DOH FAQ). The same law added public need to what PHHPC must consider, and a county need test replaced the moratorium from April 1, 2020 (PHL s. 3605(4)(a); 10 NYCRR 765-1.16).

To see what that means in practice, we read PHHPC’s agendas and staff reports from January 2024 to September 17, 2026. This is our count, not an official statistic.

What the rebuttal took. For the Monroe County approval, PHHPC’s staff report says: "A rebuttal to the presumption of no need was submitted for Monroe County, which was determined by the Department to be sufficient based on the criteria set forth in 10 NYCRR §765-1.16(d)." The applicant gave demographic data for the county and addressed subpopulations, cultural needs and waiting lists (PHHPC, June 2024).

A note on license dates. DOH’s 2026 registration list shows license dates of 31 in 2024 and 11 in 2025, but a change of owner gets a new license number, so most recent dates are ownership changes, not new agencies (Health Data NY, our count).

We did not check agendas before 2024, so we cannot say whether 2024 to 2026 is typical.

"The commissioner shall designate each county as a separate planning area." (10 NYCRR 765-1.16(b)) "There shall be a rebuttable presumption of no need for additional licensed home care service agencies in a planning area if there are 5 or more Licensed Home Care Service Agencies (LHCSA) actively serving patients within the planning area" (10 NYCRR 765-1.16(c)(1)).

• What "actively serving" means. DOH counts an agency as actively serving a county when it has a plan of care in place and is serving at least 25 patients there. The 25-patient figure for the presumption is DOH’s, from its FAQ and need report, not in the rule’s presumption text in (c)(1); the rule does use 25 patients for the ownership-change exemption in (c)(2) (DOH FAQ C, Q3-Q4).
• The date need is measured. "The target date for the Department to determine need has been adjusted to April 1, 2022" (DAL DHCBS 22-14). We found no later date and no newer county list on DOH’s site on October 3, 2026.
• Applying in a no-need county. "An application may still be submitted; however, it must contain a rebuttal and present data-driven evidence." (DOH FAQ C, Q2) "You will need to provide a rebuttal for each county where there is a presumption of no need." (DOH FAQ C, Q9)
• The factors. Factors include demographics and health status, documented waiting lists, the number and capacity of existing agencies, their quality, workforce availability, training resources, cultural competency and subpopulations needing specialty services. (10 NYCRR 765-1.16(d))
• A commitment for every new applicant. A new applicant meets public need only if it agrees to serve groups in the county who have difficulty getting LHCSA care because of minority status, age, medical history, case complexity, payment source or location. (10 NYCRR 765-1.16(e))

Routes that skip the need review. Buying an agency that is actively serving at least 25 patients (10 NYCRR 765-1.16(c)(2)), and an agency owned by the same people as an Assisted Living Program, PACE program, Nurse-Family Partnership or continuing care retirement community that serves only that program’s people (10 NYCRR 765-1.16(c)(3)). What you can do.

DOH says: "It is difficult to give an exact timeframe for completion as there are many steps in the licensure process." Applications are reviewed in the order DOH acknowledged them (DOH FAQ A, Q3). PHHPC’s staff reports print each application’s acknowledgement date, so we compared them with the meeting dates. These are our readings of the agendas:

• New agency, with a rebuttal: acknowledged in December 2022, approved in June 2024, about 18 months (project 222202-E).
• New agency, presumed-need county: acknowledged on June 7, 2023, approved in December 2024, about 18 months (project 231215-E).
• Ownership changes, late 2025: Of the 13 LHCSA ownership changes on PHHPC’s November and December 2025 agendas, 10 had been acknowledged between June 13, 2023 and January 23, 2024, about 2 to 2.5 years earlier; three later ones had waited about 7 to 13 months (our reading). Priority Care’s new-agency application, acknowledged in December 2022, was approved in June 2024. (PHHPC, November and December 2025).
• Ownership changes, September 2026: the four on the agenda had been acknowledged between June 7, 2024 and February 20, 2025, about 19 months to 2 years 3 months earlier (PHHPC, August and September 2026).

After the vote, you send the manual, DOH reviews it, and the regional office schedules the pre-opening survey. DOH publishes no time for those steps, and "within one year of issuance of the Public Health Council's approval or contingent approval of the application shall constitute an abandonment" (10 NYCRR 765-1.7), so have the manual and your RN ready before PHHPC votes.

New York is one of the hardest states to enter with a brand new agency. That is not a reason to give up on home care, but it is a reason to plan around the rules rather than against them.

A license does not come with the business: "A LHCSA license is not transferrable." A new operator needs PHHPC approval, and DOH issues a new license with a new license number while the seller surrenders theirs (DOH FAQ E, Q6).

• The agency must be operating. DOH allows a change of operator or ownership only if the existing agency is actively serving at least one patient and is registered under PHL s. 3605-b. To skip the need review, it must be actively serving at least 25 patients, counted across its counties. (DOH FAQ E, Q2 and Q4)
• The need review. "Applications for licensure based on change of ownership for Licensed Home Care Service Agencies actively serving at least 25 patients will not be subject to public need review", unless you want to serve counties outside its approved area (10 NYCRR 765-1.16(c)(2)). PHHPC still reviews your character, competence and finances.
• The manual. DOH says "the applicant (buyer) may choose to adopt the approved Policy & Procedures manual that is currently in use from the existing (seller) agency", and that this speeds licensing (DOH FAQ A, Q3). DOH may still ask for agency-specific materials.
• The fee and the forms. The same $2,000 state application fee applies to a change of ownership (PHL s. 3605(13); DOH FAQ B). The application asks for organizational charts of the current and proposed ownership and the current operating costs of the agency you are buying (DOH application, Sections F and G).
• The wait. Most ownership changes on PHHPC’s 2025 and 2026 agendas had waited about 19 months to 2.5 years since acknowledgement, and a few waited less (Real waits).
• Medicaid. Since July 27, 2026, Medicaid enrollment applications for LHCSA ownership changes are paused for six months. DOH’s recommended conditions for ownership changes on PHHPC’s August and September 2026 agendas tell the new operator to enroll after the moratorium before serving Medicaid members (Medicaid: the 2026 freeze).

Get a New York health care lawyer before you sign: whether a deal is an asset purchase, a new operator or a transfer of ownership interest changes what PHHPC must approve.

Payment. The application fee is paid by check to the New York State Department of Health within 30 days of submission. "Application fees are not refundable once the application has been acknowledged." (DOH FAQ B, Q1 and Q3), even if PHHPC disapproves it.

Working capital. Applicants must show working capital of at least two months of estimated operating expenses, pass a reasonableness test, and show revenue will cover expenses over time. (10 NYCRR 765-1.2(b)(3)(i)) A CPA must confirm the working capital available (balance sheet and CPA letter, or personal financial statements on CPA letterhead for equity contributions). First- and third-year operating cost estimates are required. (DOH application, Section G) "A loan or grant will only be considered working capital if the award was made prior to or at the time of application and supportive documentation is submitted." (DOH FAQ D, Q5)

Other costs we cannot price. The CPA’s fee (DOH says the applicant pays all costs of developing and submitting the application, including the CPA (DOH FAQ D, Q7)), legal advice, an RN on staff before the pre-opening survey, and printing the manual. We found no insurance minimum in Parts 765 or 766.

Every New York LHCSA is RN-led, including private-pay personal care. The rule says the governing authority must "employ at least one licensed and currently registered professional nurse" responsible for directing and supervising all patient care (10 NYCRR 766.9(h)). DOH’s application goes further: "at least one Registered Nurse must be employed directly by the agency for the purpose of supervision of Home Health Aides and/or Personal Care Aides"; nursing services beyond that may be contracted (DOH application, Section B).

• Accepting patients. "All patients are accepted for health care services only after a determination has been made by a registered professional nurse" (or someone the RN directly supervises) that the agency can meet the patient’s needs (10 NYCRR 766.3(a)).
• Plan of care. Each patient has a plan of care based on a professional assessment, reviewed as needed and at least every six months. (10 NYCRR 766.3(b), (d))
• Supervising aides. Home health aides and personal care aides are supervised by an RN (or a therapist for simple therapy procedures), with in-home visits to instruct and evaluate. (10 NYCRR 766.5(c), (d))
• Quality improvement. The governing authority appoints a QI committee with a consumer and health professionals that meets at least four times a year to review policies and clinical records and report to the governing authority. (10 NYCRR 766.9(l)) The application adds: "Please note: The Quality Assurance Committee must include at least one nurse." (DOH application, Section F)

Physician orders

The statute defines personal care services as services that a physician prescribes under a plan of home care supervised by a registered nurse; a nurse practitioner may also prescribe or order them where the law allows (PHL s. 3602(5), Public.Law copy). The LHCSA rule is narrower: an authorized practitioner’s order is needed for patients under active treatment for a diagnosed problem, with a health need needing medical intervention, or who are aide patients of a certified home health agency; orders are reviewed at least every six months (up to a year for Medicaid personal care). (10 NYCRR 766.4)

The EISEP exception. DOH and the Office for the Aging told LHCSAs that clients admitted for the non-medical EISEP program (age 60+, not Medicaid-eligible) need no physician orders, and surveys will reflect this. In DOH’s words: "As the program is non-medical, physician orders are not necessary." (DAL DHCBS 26-01, January 2, 2026)

Our reading: outside EISEP, plan on practitioner orders for personal care clients. The statute defines personal care as prescribed, and we found no DOH statement exempting other private-pay clients. Ask DOH how it applies 766.4 to private-pay clients who are not under active treatment.

Training

• Hours. DOH: personal care aides need at least 40 hours of training and home health aides at least 75 hours, from an approved program, with valid certificates. (DAL DHCBS 25-02) A personal care aide may also qualify through a home health aide program (10 NYCRR 700.2(b)(14)).
• No more competency shortcut. On July 16, 2026, DOH wrote that "the Department is discontinuing the Alternative Competency Demonstration provision for Personal Care Aide certification." Everyone seeking personal care aide certification now completes a basic training program of at least 40 hours (DAL DRS 26-02 / DHCBS 26-05). "Department-approved Personal Care Aide Training Programs are prohibited from charging candidates a fee" (same letter)
• Every year. Personal care aides need 6 hours of in-service education a year, home health aides 12 and advanced home health aides 18. Medicaid personal care adds 3 hours every six months. (10 NYCRR 766.11(i); 18 NYCRR 505.14(e)) "All in-service education must be done under the supervision of an RN" (DAL DHCBS 21-09)
• LGBTQIA+ affirming care. Home health aides and personal care aides take the Affirming Care for Older LGBTQIA+ Individuals training at certification and recertification; existing aides must take it too. (DAL DRS 25-02)

Before an aide starts

• Home Care Worker Registry. Before an aide starts, the agency checks the Home Care Worker Registry; it records the aide’s employment within 10 business days of hire and updates it within 10 business days of termination. (10 NYCRR 403.5)
• Criminal history record check. The agency submits a fingerprint-based criminal history record check through DOH for each prospective unlicensed direct care employee (volunteers and licensed staff are excluded). (10 NYCRR 402.6(a)) First, the agency asks each applicant for a sworn statement disclosing any prior finding of patient or resident abuse or any criminal conviction (PHL s. 2899-a(2); 10 NYCRR 402.5(a)).
• While the check is pending. A prospective employee may start while results are pending, with direct observation on site in the home in the first week, then at least every other week (phone contacts allowed on alternate weeks), documented in the personnel file. (10 NYCRR 402.4(b)(2)(ii))
• No cost to workers. Agencies may not charge applicants or employees for criminal history check fees or costs. (10 NYCRR 402.4(e)) Employers may not charge, or send other employers to paid vendors, to verify a worker’s employment history. (DAL DHCBS 22-10)
• Who runs the checks. DOH’s March 2026 letter says CHRC authorized persons should be agency staff, not a third-party contractor, with no shared Health Commerce System logins and criminal history kept separately. (DOH letter, March 20, 2026)

Reporting abuse

Registered nurses are among the professionals who must report suspected child abuse or maltreatment. (Social Services Law s. 413, Public.Law copy) By our reading, New York has no general duty for home care agencies or aides to report suspected abuse of adult clients; we found none in the rules we saved, so ask a New York lawyer what your policy should say. Complaints about home care go to DOH’s hotline, 1-800-628-5972 (DOH, Information for Consumers), and agencies respond in writing within 15 days to written complaints, and to oral ones on request (10 NYCRR 766.9(j)).

When. "Policy and Procedure Manuals must be submitted AFTER the LHCSA application has been approved by the Public Health and Health Planning Council (PHHPC) and Department of Health." (DOH LHCSA page) It goes to the DOH home care regional office for your area.

• On paper. "All materials must be submitted in hard copy to the appropriate Regional Office. Electronic copies will not be accepted." DOH’s guidance asks for a hard-covered binder with dividers (DOH guidance, Submission item 2 and All submissions should).
• An index and a crosswalk. The manual needs an index listing each policy’s name, number, the regulation or DOH directive it addresses and review dates, plus a crosswalk from policies to regulations. (DOH guidance, Submission item 4)
• Format. Policies should be written in Microsoft Word, at least 12 point, with "Page 1 of X" numbering for each policy. Each policy shows the agency name as approved by PHHPC, a policy number, title, purpose, dates, page numbering, authority, application, responsible party, terminology, cross-references and a step-by-step procedure. (DOH guidance, Writing a Policy)
• DOH’s directives too. "Guidance and policy directives issued by the Department supplement the regulatory requirements and also must be incorporated into the agency’s policies and procedures." (DOH guidance, Background)
• The worksheet. "This worksheet must be submitted with the Policy and Procedure Manual." "A policy must be submitted for each service requested by the applicant." (DOH applicant worksheet, page 1)

DOH’s review tool

DOH publishes the two-part tool its reviewers use. Part A checks the minimum list: patient rights, complaints, admission, discharge, plan of care, assessment, medical orders, clinical supervision, clinical records, QA/QI, contracts, Health Commerce System, personnel, criminal history checks and the Home Care Registry (if aides), infection control, ownership change and license amendment, governing authority, emergency preparedness; plus a policy and job description for each approved service (nursing is required). (Review Tool Part A, pages 4 to 5). Part B scores each policy against the regulation text: "Regulation language is copied from 10 NYCRR Parts 765, 766, 402 and 403." (Review Tool Part B, instructions).

A New York manual is more clinical than most states’ because the RN’s duties (acceptance, assessment, plans of care, orders and aide supervision) each need a policy. Buyers of an existing agency can adopt the seller’s approved manual instead (Buying an existing LHCSA).

• Register every year. A LHCSA license has no expiry date in the statute, but the agency must register with DOH every year to operate or be paid. (PHL s. 3605-b(1)(a)) Agencies register for 2027 by filing the 2025 LHCSA Statistical Report through the Health Commerce System by December 31, 2026; agencies licensed in 2026 complete the registration part. (DAL DHCBS 26-06) Late registration costs $500 for each month or part month, and missing two registration periods leads to revocation proceedings (PHL s. 3605-b(1)(b), (d)).
• The Health Commerce System. Agencies keep Health Commerce System (HPN) accounts with 24/7 emergency contacts and a written HPN coverage policy reviewed at least yearly. DOH’s 2025 letter says to check the system daily and fill set roles, including CHRC authorized person and registry roles for aide agencies. (10 NYCRR 766.9(o)) "The HCS should be accessed daily." (DAL DHCBS 25-10)
• The SHIN-NY. Under 10 NYCRR 300.6, LHCSAs must connect to the Statewide Health Information Network for New York, starting by signing the Statewide Common Participation Agreement with a health information network. (DAL DHCBS 25-14)
• Changes. An existing LHCSA adding nursing, home health aide or personal care services applies at least 90 days ahead and needs written DOH approval first; other services need 30 days’ notice. (10 NYCRR 765-2.2) Adding or removing a service, county or site can be approved administratively by the DOH regional office (procedure revised January 13, 2026), without PHHPC. (DOH FAQ F, Q2; DAL DHCBS 26-02)
• Offices. Tell DOH in writing at least 10 days before moving or adding an office; DOH’s 2021 letter says recruitment or satellite offices need regional office approval first, with no services or records there. (DAL DHCBS 21-07; 10 NYCRR 765-2.2(d)) DOH’s July 2021 letter allowed remote agency operations only during the declared COVID-19 State of Emergency and said DOH would give an update. We found no later DOH statement on remote or home-based offices. (DAL DHCBS 21-07)
• Management contracts. A management contract takes effect only with the Commissioner’s prior written consent (submitted at least 60 days ahead); franchise agreements likewise. (10 NYCRR 766.9(m), (n))
• Records. Patient records are kept securely for at least six years after discharge (for minors, the longer of six years or three years after age 18). (10 NYCRR 766.6)
• Closing. Closing, stopping nursing, aide or personal care services, or surrendering the license needs 30 days’ written notice to DOH with a plan for patients and records, and DOH’s written approval. (10 NYCRR 765-2.3(a)) Since January 2026, closing a site or surrendering a license is handled through a separate regional office process, not the administrative amendment procedure. (DAL DHCBS 26-02)
• Surveys. We did not find a set survey frequency for licensed LHCSAs in Article 36 or Part 766.

DOH’s 2026 registration list (rows updated June 5, 2026) has 1,266 LHCSA licenses, 1,203 of them registered for 2026. Going by the first four characters of the license number, about 934 operators hold them. By DOH region, the list has 597 licenses in New York City, 189 on Long Island and 480 in the other five regions (Health Data NY, our count). DOH’s list is the place to look for an agency’s registration status before you talk to a seller.