West Virginia - Assisted Living Facility — Licensing, Medicaid Enrollment and Startup Requirements

Last reviewed: 2026-09-10

West Virginia licenses Assisted Living Residences (ALRs) through the Office of Health Facility Licensure and Certification (OHFLAC), but the Bureau for Medical Services (BMS) does not cover assisted living as a distinct Medicaid waiver service or facility rate. Facilities operating in West Virginia are primarily private-pay, though operators may separately seek a Certificate of Need (CON) from the West Virginia Health Care Authority to enroll as Medicaid Personal Care providers under Chapter 517 to deliver personal care hours to eligible residents.

Approval requires passing OHFLAC's architectural plan review, life safety inspections, and an initial on-site licensure survey. Because Medicaid does not pay for room, board, or bundled ALF care, facilities relying on Medicaid revenue must navigate the CON process to bill fee-for-service personal care, which requires demonstrating unmet regional need before an application is even accepted.

1. Service Definition and Scope

In West Virginia, an Assisted Living Residence (ALR) is defined as a living arrangement providing personal assistance, supervision, and housing to four or more individuals. Because West Virginia Medicaid does not have an Assisted Living Waiver, the state does not define a Medicaid-specific ALF tier; instead, facilities provide housing and care under their OHFLAC license, and residents may independently qualify for Medicaid Personal Care Services (Chapter 517) for specific ADL assistance.

• Licensure Term: Assisted Living Residence (ALR)
• Medicaid Status: Not covered as a bundled Medicaid service; room and board are strictly private pay
• Personal Assistance: Includes help with walking, bathing, dressing, feeding, and supervision
• Nursing Care: Limited to procedures prescribed by a physician that require technical skills, such as medication administration by Approved Medication Assistive Personnel (AMAP)
• Capacity Threshold: Licensure as an ALR is required when serving four or more unrelated residents
• Special Care Units: Facilities offering Alzheimer's/Dementia Special Care Units (ASCU) must meet additional disclosure and staffing rules under WV CSR §64-75

2. Regulatory and Oversight Agencies

The Office of Inspector General's Office of Health Facility Licensure and Certification (OHFLAC) is the primary regulatory body for ALRs in West Virginia. The Bureau for Medical Services (BMS) oversees Medicaid policy, but only interacts with ALRs if they separately enroll as Personal Care Agencies.

• Licensing Agency: Office of Health Facility Licensure and Certification (OHFLAC) (https://ohflac.wvdhhr.org/)
• Medicaid Authority: West Virginia Bureau for Medical Services (BMS) (https://dhhr.wv.gov/bms/)
• Need Determination: West Virginia Health Care Authority (WVHCA) (https://hca.wv.gov/)
• Background Checks: West Virginia State Police and the WV DHHR Protective Services Record
• Ombudsman: West Virginia State Long-Term Care Ombudsman program

3. Gatekeeping Prerequisites: Who Can Even Apply

West Virginia imposes a strict Certificate of Need (CON) requirement for any entity wishing to provide Medicaid Personal Care Services. While an ALR can be licensed for private-pay residents without a CON, accessing Medicaid reimbursement for personal care delivered within the facility requires prior approval from the West Virginia Health Care Authority.

• Medicaid Personal Care Gate: Certificate of Need (CON) from the WV Health Care Authority is required before applying for Medicaid Personal Care certification
• Exemptions: ALRs operating strictly as private-pay facilities do not require a CON for licensure
• Architectural Review: OHFLAC requires approved architectural plans before an initial licensure application is processed
• Administrator License: The facility must employ a licensed ALR Administrator approved by the state before opening
• Medicaid Waiver Exclusion: There is no open enrollment for an Assisted Living Medicaid Waiver because West Virginia does not operate one

4. Licensure and Certification Requirements

ALR licensure is managed by OHFLAC under WV CSR §64-14. Applicants must submit a detailed application, architectural plans, and pass life safety and health inspections before admitting residents.

• Application Form: OHFLAC Initial Assisted Living Residence Licensure Application
• Plan Review: Submission of construction or renovation plans to the OHFLAC Life Safety Division and the State Fire Marshal
• Initial Survey: On-site inspection by OHFLAC surveyors to verify compliance with physical plant and operational rules
• Alzheimer's Certification: Separate compliance evaluation during the state survey for facilities operating an ASCU under WV CSR §64-75
• Capacity Limits: License specifies the maximum number of beds; exceeding this requires a formal bed addition request

5. Medicaid Provider Enrollment

Because ALRs cannot enroll as bundled Medicaid assisted living providers, facilities seeking Medicaid revenue must enroll as Personal Care Agencies under Chapter 517. This requires submitting the CON and an Operating Agency Certification Application to BMS.

• Enrollment Portal: West Virginia Medicaid Provider Enrollment Portal (Gainwell Technologies) (https://www.wvmmis.com/)
• Provider Type: Personal Care Agency (requires CON)
• NPI Requirement: Must obtain a Type 2 National Provider Identifier (NPI) for the agency
• Certification Application: Must submit a Certification Application to the Operating Agency after receiving the CON
• Business License: Valid West Virginia state business license and FEIN required

6. Staffing, Training and Background Checks

OHFLAC mandates strict background checks and training for all ALR staff. If the facility also provides Medicaid Personal Care, staff must meet the qualifications outlined in BMS Chapter 517.

• Criminal Background Check: Fingerprint-based state and FBI criminal history check via the WV State Police contracted entity
• Registry Checks: Mandatory checks of the OIG Exclusion List, WV Nurse Aide Registry, and WV DHHR Protective Services Record
• Administrator Qualifications: Must hold a valid West Virginia ALR Administrator license
• Medication Administration: Unlicensed staff administering medications must complete the Approved Medication Assistive Personnel (AMAP) training
• CPR/First Aid: Direct care staff must hold valid American Heart Association or Red Cross CPR and First Aid certification
• Nursing Staff: Registered Nurses (RNs) overseeing care must hold a current West Virginia RN license

7. Documentation, Policies and Records

ALRs must maintain comprehensive resident and facility records subject to OHFLAC review. Medicaid Personal Care providers must retain records for five years to support claims.

• Resident Assessments: Signed medical assessment by a licensed professional dated no more than 60 days prior to admission
• Service Plans: Individualized care plans detailing the scope of personal assistance and nursing care required
• Record Retention: Medicaid providers must keep original documentation for 5 years (or 3 years after audits are resolved)
• Personnel Files: Must contain background check results, AMAP certificates, CPR/First Aid cards, and RN licensure verification
• Disclosure Statements: ASCUs must provide specific disclosure statements regarding dementia care practices

8. Billing, Rates and Claims

ALR room and board are private pay. Medicaid reimbursement is limited to fee-for-service Personal Care (Chapter 517) billed through the WVMMIS system for eligible residents.

• Room and Board: Strictly private pay; not reimbursable by West Virginia Medicaid
• Personal Care Billing: Billed in 15-minute increments under specific HCPCS codes if enrolled as a Personal Care Agency
• Prior Authorization: Medicaid Personal Care requires a Pre-Admission Screening (PAS) to certify medical eligibility
• Claim Submission: Claims are submitted electronically via the WVMMIS portal
• Family Member Restriction: Medicaid Personal Care cannot be reimbursed if provided by a resident's spouse

9. Approval Sequence and Timeline

The timeline to open an ALR depends heavily on construction and OHFLAC plan review. Adding Medicaid Personal Care services extends the timeline significantly due to the Health Care Authority's CON process.

• Step 1: Submit architectural plans to OHFLAC and the State Fire Marshal
• Step 2: Submit the OHFLAC Initial Licensure Application and fee
• Step 3: Pass OHFLAC Life Safety and Health inspections
• Step 4: (Medicaid Only) Apply for and obtain a Certificate of Need from the WV Health Care Authority
• Step 5: (Medicaid Only) Submit Certification Application to the Operating Agency and enroll via WVMMIS

10. Common Denials and Survey Findings

OHFLAC frequently cites facilities for life safety violations and medication administration errors. Medicaid enrollment is most commonly blocked by the inability to secure a CON.

• CON Denial: Failure to prove unmet regional need for Personal Care Services results in Health Care Authority denial
• Background Check Violations: Hiring staff with disqualifying convictions or abuse registry hits
• AMAP Lapses: Unlicensed staff administering medications without current AMAP certification
• Assessment Delays: Admitting residents without the required medical assessment completed within 60 days prior
• Life Safety Deficiencies: Failure to maintain egress routes or fire suppression systems

11. Key Contacts and Resources

Providers must coordinate with OHFLAC for licensure and BMS for any Medicaid personal care enrollment. The WVMMIS portal is the hub for Medicaid billing.

• OHFLAC: Office of Health Facility Licensure and Certification (https://ohflac.wvdhhr.org/)
• BMS: West Virginia Bureau for Medical Services (https://dhhr.wv.gov/bms/)
• WVHCA: West Virginia Health Care Authority (https://hca.wv.gov/)
• Medicaid Portal: WVMMIS Provider Portal (https://www.wvmmis.com/)
• Regulations: WV Code §16B-6 and CSR §64-14 (Assisted Living Residences)

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