Washington - Skilled Nursing Services — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-08-16

In Washington State, Medicaid Home and Community-Based Services (HCBS) skilled nursing—often referred to as Private Duty Nursing (PDN) or waiver skilled nursing—provides complex, physician-ordered medical care delivered by Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) in a client's home. These services support medically fragile children and adults enrolled in waivers managed by the Department of Social and Health Services (DSHS), such as the Community First Choice (CFC) or Developmental Disabilities Administration (DDA) waivers, allowing them to avoid institutionalization.

The single biggest structural barrier to entry for this service in Washington is the prerequisite to obtain an In-Home Services Agency license with a "Home Health" category from the Washington State Department of Health (DOH) before any Medicaid enrollment can begin. While Washington does not require a Certificate of Need (CON) for home health agencies, passing the rigorous DOH initial licensure survey and subsequently securing a Core Provider Agreement (CPA) through the Health Care Authority (HCA) requires significant upfront capital, clinical policy development, and operational readiness.

1. Service Definition and Scope

Skilled Nursing Services under Washington's Medicaid HCBS waivers provide direct, intermittent, or continuous nursing care to clients in their own homes. These services are strictly limited to tasks that require the clinical judgment and licensure of an RN or LPN and cannot be legally or safely delegated to a certified home care aide.

Services must be ordered by a physician and authorized by a DSHS case manager through the Comprehensive Assessment Reporting Evaluation (CARE) system. The scope of practice is governed by the Washington State Board of Nursing (WABON).

• Service Modality: Direct clinical care delivered in the client's residence by an RN or LPN under a physician's established plan of care.
• Covered Tasks: Comprehensive nursing assessments, complex medication administration (e.g., IV therapy), wound care, ventilator management, and enteral tube feedings.
• Target Populations: Medically fragile children and adults enrolled in DSHS Aging and Long-Term Support Administration (ALTSA) or DDA waiver programs.
• Exclusions: Routine personal care or basic medication assistance that can be safely delegated to a Home Care Aide-Certified (HCA-C) under Washington's Nurse Delegation rules (WAC 246-840-910).
• Authorization: Requires prior authorization and a specific service plan developed by a DSHS or DDA case manager before care can commence.

2. Regulatory and Oversight Agencies

Oversight of skilled nursing providers in Washington is divided among health regulation, Medicaid finance, and waiver administration agencies. Providers must maintain compliance with all of these bodies simultaneously to operate and bill legally.

The Department of Health handles the facility-level licensure, while the Health Care Authority manages the financial and enrollment aspects of Medicaid. DSHS acts as the operational manager for the specific HCBS waiver programs.

• Washington State Department of Health (DOH): Licenses In-Home Services Agencies under the Home Health category and conducts compliance surveys (https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/home-health-agencies).
• Washington State Health Care Authority (HCA): Administers Washington Apple Health (Medicaid) and operates the ProviderOne enrollment and billing portal (https://www.hca.wa.gov/billers-providers-partners/become-apple-health-provider).
• Department of Social and Health Services (DSHS) ALTSA: Manages adult HCBS waivers, authorizes client care plans, and issues provider contracts (https://www.dshs.wa.gov/altsa).
• DSHS Developmental Disabilities Administration (DDA): Manages HCBS waivers specifically for individuals with developmental disabilities (https://www.dshs.wa.gov/dda).
• Washington State Board of Nursing (WABON): Regulates individual RN and LPN licensure, scope of practice, and Nurse Delegation rules (https://nursing.wa.gov).

3. Gatekeeping Prerequisites: Who Can Even Apply

Washington State maintains an open market for Home Health Agencies; there is no Certificate of Need (CON) required, nor are there county-level sponsorships, moratoria, or closed-network procurement (RFP) requirements blocking new entrants. Any entity that meets the clinical and financial standards may apply.

However, the absolute structural precondition is that an applicant cannot enroll directly with Medicaid as a standalone "skilled nursing provider" entity. The applicant must first successfully establish a physical office in Washington and obtain an In-Home Services Agency license with the "Home Health" category from DOH. Only after this license is in hand will the HCA accept a Medicaid enrollment application.

• Certificate of Need (CON): Not required for Home Health Agencies in Washington (unlike hospices or hospitals); the market is open to new applicants.
• Agency Licensure Prerequisite: Must obtain a DOH In-Home Services Agency license (Home Health category) before any Medicaid enrollment application is accepted.
• Physical Location: Must maintain a physical office in Washington State that is open during standard business hours to accommodate DOH surveyors and secure records.
• Medicare Certification: While standard Medicaid Home Health requires Medicare certification, specific HCBS waiver contracts (like Private Duty Nursing) may allow enrollment with just the DOH Home Health license and a DSHS contract.
• Network Affiliation: No mandatory closed-network subcontracting; providers enroll directly with HCA via ProviderOne and contract directly with DSHS.

4. Licensure and Certification Requirements

To provide skilled nursing in the home, an agency must be licensed by the DOH Community Health Systems division under RCW 70.127 and WAC 246-335. Washington consolidates home care, home health, and hospice under a single "In-Home Services Agency" license, but providers must specifically apply for and meet the standards of the "Home Health" category.

The application process requires submitting comprehensive operational policies, clinical procedures, and organizational charts. DOH will conduct an initial on-site survey to verify readiness before granting the license.

• License Type: In-Home Services Agency License with the "Home Health" service category.
• Governing Rules: Regulated under RCW 70.127 and WAC 246-335.
• Application Form: DOH In-Home Services Application (PDF) submitted with all required clinical policies, procedures, and ownership disclosures.
• Licensing Fees: Based on a sliding scale of Full-Time Equivalents (FTEs); initial fees typically range from $2,500 to over $3,500 depending on agency size.
• Initial Survey: DOH conducts a mandatory on-site initial licensure survey to review physical space, records, and staff credentials before granting the full license.
• License Term: The initial license is valid for 12 months; subsequent renewal licenses are valid for 24 months.

5. Medicaid Provider Enrollment

Once the DOH license is secured, the agency must enroll in Washington Apple Health (Medicaid) through the HCA's ProviderOne portal. This establishes the agency as a recognized billing entity in the state's Medicaid Management Information System (MMIS).

Enrollment requires signing a Core Provider Agreement (CPA). For HCBS waiver services, the agency must subsequently execute a specific contract with DSHS ALTSA or DDA to receive client referrals and authorizations.

• Enrollment Portal: Applications are submitted electronically through ProviderOne (https://www.hca.wa.gov/billers-providers-partners/providerone).
• Provider Type: Enroll as a Billing Provider under the Home Health Agency or Private Duty Nursing taxonomy.
• Application Fee: Must pay the federal institutional provider application fee, which is $730 for 2024/2025, unless waived by proof of recent Medicare enrollment.
• Required Identifiers: Must possess an active organizational National Provider Identifier (NPI) and a completed CAQH ProView profile.
• Core Provider Agreement (CPA): Must sign the HCA CPA, legally binding the agency to Washington Medicaid's billing and compliance rules.
• DSHS Contracting: After HCA enrollment, providers must contact DSHS ALTSA or DDA to execute the specific HCBS waiver contract required to serve waiver clients.

6. Staffing, Training and Background Checks

Agencies must employ highly qualified nursing staff licensed by the Washington State Board of Nursing (WABON). Washington participates in the Nurse Licensure Compact (NLC), allowing nurses with active Multistate Licenses (MSL) to practice in the state.

Washington enforces strict background check requirements. All staff with unsupervised access to vulnerable adults or children must clear a fingerprint-based background check through the DSHS Background Check Central Unit (BCCU) before providing care.

• Clinical Leadership: Must designate a Clinical Director (an RN) responsible for the oversight of all nursing services, staff competency, and care plan approvals.
• Nurse Licensure: RNs and LPNs must hold an active Washington license or a valid Multistate License (MSL) through the NLC.
• Background Checks: Mandatory fingerprint-based background checks processed through the DSHS BCCU (using Washington State Patrol and FBI data) for all direct care staff.
• Suicide Prevention Training: All nurses must complete a WABON-approved suicide prevention training course as a condition of state practice.
• Supervision: LPNs must practice under the direct or indirect supervision of an RN, with supervisory visits documented per WAC 246-840.
• CPR Certification: All direct care nursing staff must maintain active, in-person CPR/Basic Life Support (BLS) certification.

7. Documentation, Policies and Records

DOH and HCA require extensive documentation to ensure patient safety and compliance with WAC 246-335. Agencies must maintain robust clinical records that justify the medical necessity of the skilled nursing services provided.

Records must be kept secure, confidential, and immediately available for unannounced state surveys or HCA audits.

• Plan of Care: Must maintain a physician-ordered plan of care for every client, reviewed, updated, and signed by the physician at least every 60 days.
• Clinical Records: Comprehensive documentation of all nursing assessments, clinical interventions, medication administrations, and patient responses to treatment.
• Quality Assurance: Must implement a Quality Improvement (QI) program that systematically reviews clinical outcomes, adverse events, and infection rates.
• Emergency Preparedness: Written policies for emergency response, natural disasters, and continuity of care, especially critical for ventilator-dependent clients.
• Infection Control: Documented adherence to CDC and DOH infection control guidelines, including a formal bloodborne pathogen exposure control plan.
• Record Retention: Clinical and billing records must be retained for a minimum of six years following the client's discharge or last date of service.

8. Billing, Rates and Claims

Claims for skilled nursing and Private Duty Nursing are submitted electronically through the ProviderOne MMIS. Services are reimbursed on a fee-for-service basis according to rates established by the Washington State Legislature and published by HCA/DSHS.

Agencies can only bill for services that have been explicitly authorized in the client's CARE system service plan. Medicaid is the payer of last resort, meaning agencies must exhaust third-party liability (TPL) before billing ProviderOne.

• Billing System: All fee-for-service and HCBS waiver claims are submitted via the ProviderOne MMIS.
• Prior Authorization: Services must be authorized in the DSHS/DDA CARE system; billing without a matching CARE authorization will result in automatic claim denial.
• Billing Codes: Typically billed using HCPCS codes such as T1002 (RN services) and T1003 (LPN services), usually in 15-minute increments or established per-visit rates.
• Rate Structure: Fixed fee schedule set by HCA/DSHS; rates vary depending on the complexity of care (e.g., standard nursing vs. specialized ventilator care).
• Third-Party Liability (TPL): Agencies must bill Medicare or private commercial insurance first if the client has dual coverage; Medicaid pays only the remaining eligible balance.
• Timely Filing: Claims must generally be submitted within 365 days of the date of service to be eligible for reimbursement.

9. Approval Sequence and Timeline

The end-to-end process from business formation to billing Washington Medicaid typically takes 9 to 18 months. The most time-consuming phase is the DOH licensure process, which involves extensive policy review and scheduling the initial on-site survey.

Providers cannot expedite the Medicaid enrollment phase until the DOH license is fully issued, making sequential planning critical for cash flow management.

• Step 1: Business Formation & NPI: Register the business with the WA Secretary of State and obtain an organizational NPI (1-2 weeks).
• Step 2: DOH Application: Submit the In-Home Services Agency application and all required policies to DOH (initial review takes 3-6 months).
• Step 3: Initial Survey: DOH conducts an on-site survey once the agency is operational and ready to serve patients (scheduled within 3-6 months of application approval).
• Step 4: License Issuance: DOH issues the Home Health category license (1-2 weeks post-survey clearance).
• Step 5: ProviderOne Enrollment: Submit the HCA Medicaid enrollment application and pay the $730 fee (processing takes 30-60 days).
• Step 6: DSHS Contracting: Execute specific HCBS waiver contracts with ALTSA or DDA to begin receiving client authorizations (30-90 days).

10. Common Denials and Survey Findings

DOH and HCA strictly enforce compliance, and new agencies frequently face delays or survey citations due to administrative oversights. Applications are often rejected because submitted policies are generic and do not explicitly map to Washington's WAC 246-335 requirements.

During surveys, DOH focuses heavily on clinical documentation, staff credentialing, and adherence to the physician's plan of care.

• Incomplete Policies: DOH applications delayed or denied because submitted policies lack specific references to Washington state laws (RCW/WAC).
• Care Plan Deviations: Surveyors frequently cite agencies for nurses performing tasks or administering medications outside the explicit, physician-approved plan of care.
• Background Check Lapses: Severe citations for allowing staff to provide direct care before the DSHS BCCU fingerprint background check has officially cleared.
• Supervision Failures: Lack of documented, timely RN supervisory visits for LPNs or delegated tasks.
• ProviderOne Errors: Medicaid enrollment denied due to mismatched taxonomy codes, missing W-9 forms, or failure to pay the required application fee.
• Inadequate Training Records: Missing proof of mandatory suicide prevention training or lapsed CPR certifications in personnel files.

11. Key Contacts and Resources

Prospective providers should rely exclusively on official State of Washington resources to navigate the licensure and enrollment process. Regulations, fee schedules, and forms are updated frequently.

Use the following primary agency websites to access the most current applications, WAC citations, and provider manuals.

• DOH In-Home Services Licensing: https://doh.wa.gov/licenses-permits-and-certificates/facilities-z/home-health-agencies
• HCA Provider Enrollment (ProviderOne): https://www.hca.wa.gov/billers-providers-partners/become-apple-health-provider
• DSHS ALTSA Provider Information: https://www.dshs.wa.gov/altsa/home-and-community-services/information-providers
• DSHS DDA Provider Information: https://www.dshs.wa.gov/dda/providers-and-advocates
• Washington State Board of Nursing (WABON): https://nursing.wa.gov
• DSHS Background Check Central Unit (BCCU): https://www.dshs.wa.gov/ffa/background-check-central-unit

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