Home Health Agency (HHA) Licensing and Certification Program

The Indiana Department of Health (IDOH) licenses agencies that provide nursing services, physical therapy, occupational therapy, speech therapy, medical social worker, home health aide, and other therapeutic services to the patient at the patient's temporary or permanent residence. IDOH inspects state licensed home health agencies for quality of care to citizens of Indiana and to ensure compliance with state law and rules. IDOH also monitors agencies, on behalf of the Centers for Medicare and Medicaid Services, for quality of care for all citizens in need of those services and to ensure compliance with federal regulations.

Announcements and Current News

Acute Care Advisory Letter: AC-2019-01-HHA
Effective: December 1, 2019
Posted: November 22, 2019
Policy: To allow agencies to maintain control and prevention of Tuberculosis in the least restrictive and most cost effective manner, the IDOH is issuing a blanket waiver exempting agencies from current regulatory requirements and instituting an alternative method to achieve the intended outcome of 410 IAC 17-12-1(i). To be exempt from 410 IAC 17-12-1(i), the agency must formally adopt a nationally recognized standard; implement and follow the standard as written. Should an agency fail to meet the exemption requirement, a deficient practice citation will be written at 410 IAC 17-12-1(i). The full advisory letter may be accessed here: AC-2019-01-HHA

Subject: Register for An iQIES Account
CMS is developing an enhancement to the current assessment submission & processing and reporting systems, referred to as ASAP and CASPER, collectively known as QIES. The enhanced system is referred to as iQIES, the Internet Quality Improvement Evaluation System and will be delivered in a phased approach. The process that providers follow for submitting patient assessments will not change but the enhanced system is now Internet facing and will allow providers to submit assessments and view associated reports in one place.

For iQIES access instructions and important information, please refer to the following link: https://qtso.cms.gov/news-and-updates/register-iqies-account-action-required. If you have any general iQIES questions, please contact: iQIES_Broadcast@cms.hhs.gov.

Emergency Order Granting Temporary Blanket Waivers for Home Health Agencies

Report a Complaint or Incident to the IDOH

Report a complaint regarding a health care facility
Individuals can call or email to make complaints about care provided at any licensed or certified Indiana health care providers or suppliers.

Report an incident regarding a health care facility
The Incident Report Form is for health care facilities to notify the Indiana Department of Health of a reportable incident pursuant to the IDOH Reportable Unusual Occurrence Policy. The Incident Report Form is also for health care facility staff (nursing homes, intermediate care facilities, and hospice agencies) to report a reasonable suspicion of a crime against a resident pursuant to Federal regulations. This form is not to be used to file a complaint.

Consumer Information

Consumer Reports

Directories

Forms

Agency Changes
Select a topic below for instructions on how to submit the change to the department. Please notify the department of changes as they occur at the agency.
- Adding Services
  - CMS-1572 (Medicare providers only)
- Adding/Removing Service Area
- Agency address, e-mail, fax, and phone changes
- Medicare Agency Address Change
- Agency closure
- Agency name change (Add “doing business as” (dba) name)
- Agency name change (Legal entity name)
- Medicare Voluntary Termination
- Office Hours
- Staff Changes
  - Agency Staff Change Notification Form
- Stock Transfer
Branch Information
Select a topic below for information related to Branch questions.
Applications: Applying for Initial Licensure or Change of Ownership
Review all applicable information PRIOR to submission of application to the Department.
Initial Application
To apply for an initial license to operate a home health agency complete the “APPLICATION FOR LICENSE TO OPERATE A HOME HEALTH AGENCY” (SF 4008) and submit with $250.00 licensure fee and other required information to the Indiana Department of Health.
- Initial Licensure Application Instruction Letter
- Application for License to Operate a Home Health Agency (State Form 4008)
  Submit all documentation requested on application.
  - PDF Version
  - Word Version
Forms to be completed and returned with the application:
FOR STATE LICENSE AND STATE LICENSE SEEKING MEDICAID:
- Notice of Affiliation
- Home Health Agency Survey Report (CMS-1572)
- Home Health Agency Survey Report State License Only
- Home Health Agencies/Hospice Agencies Geographic Area Served
- Clinical Laboratory Application (HCFA-116). If applicable.
- Copy of the Articles of Incorporation or Certificate of Assumed Business Name signed by the Secretary of State for doing business in Indiana.
- SS-4 or comparable document from the Internal Revenue Service that reflects the corporation name and EIN number.
- $250.00 Licensure Fee
- Copies of current valid Indiana licenses, limited criminal history checks and resumes on staff. Please refer to Criminal History Check Information.
FOR MEDICARE:
Medicare Forms:
- Medicare Form Instruction Letter
- Health Insurance Benefit Agreement (Form CMS-1561)
- Civil Rights Certification for Medicare Provider Applicants
  - Please make sure to complete and submit the “Data Request Checklist”
- Medicare Provider/Supplier Enrollment Application (Form CMS-855A)
Change of Ownership Application
To apply for a Change of Ownership for an existing agency complete the “Application for License to Operate a Home Health Agency” (State Form 4008) and submit with the $250.00 licensure fee, applicable purchase agreement, and other required information to the Indiana Department of Health.
- Change of Ownership Application Instruction Letter
- Chow Changes
- Notice of Affiliation
- Home Health Agency Survey Report (CMS-1572)
- Home Health Agency Survey Report State License Only
- Home Health Agencies/Hospice Agencies Geographic Area Served
- Clinical Laboratory Application (HCFA-116) If applicable.
- Copy of the Articles of Incorporation or Certificate of Assumed Business Name signed by the Secretary of State for doing business in Indiana.
- SS-4 or comparable document from the Internal Revenue Service that reflects the corporation name and EIN number.
- $250.00 Licensure Fee
- Copies of current valid Indiana licenses, limited criminal history checks and resumes on new owners, officers, and administrative staff. Please refer to Criminal History Check Information.
- Signed purchase agreement from the buyer and seller with the effective date of transaction.
- Letter of intent from both the buyer/seller on agency letterhead.
For CHOW involving a Medicare CCN please complete the following forms:
Medicare Forms:
- Medicare Form Instruction Letter
- Health Insurance Benefit Agreement (Form CMS-1561)
- Assurance of Compliance (Form HHS-690)
- Civil Rights Certification for Medicare Provider Applicants
  - Please make sure to complete and submit the “Data Request Checklist”
- Medicare Provider/Supplier Enrollment Application (Form CMS-855A)
Laws / Rules
General Information
Licensure Renewals

To renew the agency’s license to operate a home health agency complete the Renewal Application for License to Operate a Home Health Agency (SF 48851) and submit with the $250.00 licensure fee to the Indiana Department of Health. In accordance with 410 IAC 17-11-3 an application for renewal of license shall be filed with the department at least sixty (60) days prior, but not sooner than ninety (90) days before, the expiration date of the current license.
If there are changes that occurred at your agency make sure all changes are made on the renewal application. Include all applicable information with the application. The application must be approved and licensure fee received PRIOR to issuance of license.
Submit the $250.00 licensure renewal fee with your renewal application (SF 48851). Make sure check or money order payable to the Indiana Department of Health. Submit application and $250.00 renewal fee to:
Indiana Department of Health
2 North Meridian Street
Attention: Cashier's Office
Indianapolis, IN 46204
OASIS

New Test Assessment Submission Process for New HHAs
This notification serves to inform you of the new test assessment submission process that new, not yet certified Home Health Agencies (HHAs) will need to follow in order to fulfill their certification requirements.
Beginning January 1, 2020, new HHAs will need to use the OASIS Validation Utility Tool (VUT), available on the iQIES homepage at https://iQIES.cms.gov/vut to submit test XML files to provide evidence of their ability to submit patient assessments to CMS. Previously, new HHAs used the QIES Assessment Submission and Processing (ASAP) system to submit test XML files.
The OASIS VUT is a software utility that can be used to validate OASIS submission files in XML format. A login to iQIES is not required to access the iQIES OASIS VUT. Upon submission, users will have the option to download a validation report displaying their submission results that can be provided to the surveyor as part of the pre-certification process.
Note: It is recommended that users access iQIES using Chrome or an Internet browser alternative to Internet Explorer. If there are any questions regarding the use of the VUT, users can contact the service desk at: help@qtso.com or by phone: 800-339-9313.
Home Health Quality Reporting Program
OASIS Data Sets
OASIS User Manuals
Spotlights and Announcements
Home Health Quality Reporting Training
For HH QRP and OASIS Guidance related questions email: homehealthqualityquestions@cms.hhs.gov.
For Technical Help related to Data Submission & Certification and Survey Provider Enhancement Reports (CASPER): Quality Improvement and Evaluation System (QIES) Technical Support Office (QTSO) Help Desk Contact:
Phone: 1-800-339-9313
Email: help@qtso.com
Website: https://qtso.cms.gov
OASIS Help: Oasishelp@health.IN.gov
Survey Reporting System (SRS)
- Survey Reporting System Quick Guide
Forms

Program Information and Policies

Home Health Care Agency Employee Drug Testing effective July 1, 2017

Registry changes effective January 14, 2008
Information on the registry for home health aides, certified nurse aides, and qualified medication aides.

Advisory Letters