How to start a home care agency in Texas (2026)

Operating hours

A written policy stating your operating hours.

"An agency must adopt and enforce a written policy identifying the agency’s operating hours."

Closure notice

If the agency closes, notify HHSC in writing within five days before closing, with the reason, where client records are kept and who holds them.

"An agency must notify HHSC in writing within five days before the permanent closure of the agency, branch office, or ADS. (1) The agency must include in the written notice the reason for closing, the location of the client records (active and inactive), and the name and address of the client record custodian."

Voluntary suspension of operationsif the agency suspends operations for 10 or more consecutive days

Before pausing operations for 10 or more days: discharge clients or arrange backup, give the survey office written notice, and post a door notice and voicemail. Tell HHSC in writing within seven days of resuming.

"Voluntary suspension of operations occurs when an agency voluntarily suspends its normal business operations for 10 or more consecutive days. ... provide written notification to the designated survey office at least five days before the voluntary suspension of operations ... An agency must notify the HHSC HCSSA licensing unit in writing no later than seven days after resuming operations."

Management changes

Tell HHSC in writing within seven days of a change of administrator, alternate administrator, chief financial officer or controlling person.

"If a change occurs in the following management personnel, an agency must submit written notice to HHSC no later than seven days after the date of a change in: (1) administrator; (2) alternate administrator; (3) chief financial officer; or (4) controlling person"

Organizational structure

A current chart or narrative of how the agency is organized.

"An agency must prepare and maintain a current written description of the agency’s organizational structure."

Administrator and alternate

Designate a qualified administrator, and designate in writing a qualified alternate who acts when the administrator is absent.

"A license holder, or the license holder’s designee, must designate an individual who meets the qualifications and conditions set out in §558.244 ... to serve as the administrator of the agency. (2) A license holder, or the license holder’s designee, must designate in writing an alternate administrator who meets the qualifications and conditions of an administrator to act in the absence of the administrator."

Survey entry designee

Name, in writing, the employee who lets HHSC surveyors in.

"An administrator must designate, in writing, an agency employee who must provide HHSC surveyors entry to the agency"

Staffing policies

Written staffing policies covering every employee, volunteer and contractor, with ten required elements.

"An agency must adopt and enforce written staffing policies that govern all personnel used by the agency, including employees, volunteers, and contractors."

Orientation and job training

Staffing policies must require orientation to agency policies and job-specific training for all personnel, with competency shown when education or experience does not prove it.

"include requirements for orientation to the policies, procedures, and objectives of the agency; (2) include requirements for participation by all personnel in job-specific training. ... ensure demonstration of competency for tasks when competency cannot be determined through education, license, certification, or experience;"

Background check procedures

Staffing policies must include procedures for criminal history checks and registry searches for unlicensed staff.

"include procedures for processing criminal history checks and searches of the nurse aide registry and the employee misconduct registry for unlicensed personnel in accordance with §558.247"

Annual registry re-check

Search the registries again for each unlicensed employee at least every 12 months. Missing it was the second most-cited violation in FY 2025.

"In addition to the initial verification of employability, the agency must search the NAR and the EMR to determine if the employee is listed as unemployable in either registry as follows: ... for an employee most recently hired on or after September 1, 2009, at least every 12 months."

Personnel records

A personnel record for every employee and volunteer.

"An agency must maintain a personnel record for an employee and volunteer."

Reporting abuse, neglect and exploitation

A written policy on how the agency reports alleged abuse, neglect and exploitation by staff.

"An agency must adopt and enforce a written policy relating to the agency’s procedures for reporting alleged acts of abuse, neglect, and exploitation of a client by an employee of the agency."

Complaint and abuse investigations

A written policy on investigating complaints and abuse reports.

"An agency must adopt and enforce a written policy relating to the agency’s procedures for investigating complaints and reports of abuse, neglect, and exploitation."

Peer review

A written policy making sure licensed professionals follow their practice acts on reporting and peer review.

"An agency must adopt and enforce a written policy to ensure that all professional disciplines comply with their respective professional practice acts or title acts relating to reporting and peer review."

Business records

Keep business records in their original state, dated and corrected by standard accounting practice, and show them to HHSC on request.

"An agency must make available to HHSC, upon request, business records relating to its ability to carry out its functions. ... An agency must maintain business records in their original state. Each entry must be accurate and dated with the date of entry."

Drug testing

A written policy saying whether you drug test direct-care staff, given to anyone applying for services.

"An agency must have a written policy describing whether it will conduct drug testing of its employees who have direct contact with clients."

Accurate billing

A written policy to keep bills and insurance claims accurate.

"The agency must adopt and enforce a written policy to ensure that the agency submits accurate billings and insurance claims."

Patient solicitation

A written policy on complying with the Texas patient solicitation law.

"An agency must adopt and enforce a written policy to ensure compliance of the agency and its employees and contractors with Texas Occupations Code Chapter 102."

Emergency preparedness

A written emergency preparedness and response plan.

"An agency must have a written emergency preparedness and response plan that comprehensively describes its approach to a disaster that could affect the need for its services or its ability to provide those services."

Emergency plan training

Orient and train employees, volunteers and contractors on their roles in the emergency plan.

"An agency must orient and train employees, volunteers, and contractors about their responsibilities in the agency’s emergency preparedness and response plan."

Administrator initial trainingfor a first-time administrator or alternate administrator

A first-time administrator and alternate each complete 24 hours of training within 12 months of designation (8 of them before), with the records on file at the agency.

"a first-time administrator and alternate administrator of an agency must each complete a total of 24 clock hours of educational training in the administration of an agency before the end of the first 12 months after designation to the position. ... Documentation of administrator and alternate administrator training must: (1) be on file at the agency;"

Administrator continuing education

12 hours of continuing education every 12 months for the administrator and alternate, with the records on file. Missing it was the fifth most-cited violation in FY 2025.

"an administrator and alternate administrator must complete 12 clock hours of continuing education within each 12-month period beginning with the date of designation. ... Documentation of administrator and alternate administrator continuing education must: (1) be on file at the agency;"

Client care practices

A written policy on client care practices, including start of care, emergencies in the home and staff safety.

"An agency must adopt and enforce a written policy that specifies the agency’s client care practices."

Client rights and grievances

A written policy on client rights and conduct, with a grievance process clients can use without fear of reprisal.

"An agency must adopt and enforce a written policy governing client conduct and responsibility and client rights, in accordance with this section. The written policy must include a grievance mechanism under which a client can participate without fear of reprisal."

Advance directives

A written advance directives policy that complies with the Advance Directives Act.

"An agency must maintain a written policy regarding implementation of advance directives. The policy must comply with the Advance Directives Act, Texas Health and Safety Code Chapter 166."

Infection control

Written infection control policies, including preventing the spread of disease.

"An agency must adopt and enforce written policies addressing infection control, including the prevention of the spread of infectious and communicable disease."

Biohazardous wasteif staff handle biohazardous waste or materials

A written policy on safely handling and disposing of biohazardous waste and materials.

"An agency must adopt and enforce a written policy for the safe handling and disposal of biohazardous waste and materials, if applicable."

Quality improvement (QAPI)

An ongoing QAPI program with a written plan, run by a committee that meets at least twice a year.

"An agency must maintain a QAPI Program that is implemented by a QAPI Committee. The QAPI Program must be ongoing, focused on client outcomes that are measurable, and have a written plan of implementation."

Coordination of services

A written policy on exchanging information and coordinating client services.

"An agency must adopt and enforce a written policy regarding coordination of services to ensure the effective exchange of information, reporting, and coordination of client services"

Backup services

A written policy so services still happen when the usual worker is unavailable.

"An agency must adopt and enforce a written policy to ensure that backup services are available when an agency employee or contractor is not available to deliver the services."

After-hours care

A written policy on teaching clients how to get care after business hours.

"An agency must adopt and enforce a written policy to ensure that clients are educated in how to access care from the agency or another health care provider after regular business hours."

Dissolution contingency plan

A written contingency plan for if the agency closes.

"An agency must adopt and enforce a written policy that describes the agency’s written contingency plan."

Service agreement

A written agreement for services given to the client or family.

"The agency must provide the client or the client’s family with a written agreement for services."

Start-of-care time frames

A written policy setting how quickly care starts.

"An agency must adopt and enforce a written policy establishing time frame(s) for the initiation of care or services."

Physician delegation

A written policy stating whether the agency accepts tasks delegated by a physician. If it does, it must follow Occupations Code Chapter 157.

"An agency must adopt and enforce a written policy that states whether physician delegation will be honored by the agency. If an agency accepts physician delegation, the agency must comply with Texas Occupations Code Chapter 157, concerning physician delegation."

Receiving physician orders

A written policy on how staff receive physician orders, including when verbal orders are countersigned and safeguards for faxed orders.

"An agency must adopt and enforce a written policy describing protocols and procedures agency staff must follow when receiving physician orders. (1) The policy must address the time frame for countersignature of physician verbal orders."

RN delegation rules

A written policy to comply with the Texas Board of Nursing delegation rules.

"An agency must adopt and enforce a written policy to ensure compliance with the following rules adopted by the Texas Board of Nursing"

Medication list and administration recordif agency staff administer medication to clients

If staff administer medication, a written policy for keeping a current medication list and a current medication administration record.

"This section applies only to clients to whom agency staff administer medications. (b) An agency must adopt and enforce a written policy for maintaining a current medication list and a current medication administration record."

Client records use and release

Written procedures on using, removing and releasing client records.

"The agency must adopt and enforce written procedures regarding the use and removal of records, the release of information"

Records retention

A written retention policy. Keep original client records at least five years after discharge.

"An agency must adopt and enforce a written policy relating to the retention of records in accordance with this subsection. (1) An agency must retain original client records for a minimum of five years after the discharge of the client."

Choice and control (PAS)

Operational policies must respect individual and family choice and flexible services.

"The agency must ensure that when developing its operational policies, the policies are considerate of principles of individual and family choice and control, functional need, and accessible and flexible services."

Individualized service plan (PAS)

A signed individualized service plan with six required elements. Missing elements were the 9th most-cited violation in FY 2025.

"individualized service plan developed, agreed upon, and signed by the client or family and the agency."

Supervision of personnel (PAS)

A written supervision policy, with client or family input on how often.

"the agency must adopt and enforce a written policy addressing the supervision of personnel with input from the client or family on the frequency of supervision."

G-tube feeding procedure (PAS)if unlicensed staff do g-tube feedings or give medication through a g-tube

Unlicensed staff may do g-tube feedings or give medication through a g-tube only after a training and competency program built on a written procedure that meets nursing standards.

"Tube feedings and medication administration through a permanently placed gastrostomy tube (g-tube) in accordance with subsection (d)(3) of this section may be performed by an unlicensed person only after successful completion of the training and competency program and procedures ... review of a written procedure for g-tube feeding or medication administration through a g-tube. The written procedure must be equivalent to current acceptable nursing standards of practice, including addressing the crushing of medications;"

Volunteersif the agency uses volunteers

Staffing policies must cover volunteers if you use them.

"address the use of volunteers, if volunteers are used by the agency."

Contractor agreementsif the agency uses independent contractors

A written contract with each independent contractor.

"If an agency uses independent contractors, there must be a contract between each independent contractor that performs services and the agency."

Workplace violence preventionif the agency employs two or more RNs

Agencies employing two or more registered nurses must run a workplace violence prevention program.

"a home and community support services agency licensed or licensed and certified under Chapter 142 that employs at least two registered nurses"