The short answer Tennessee split oversight in 2022: the independent Health Facilities Commission now licenses home health agencies (which also require a Certificate of Need), while non-medical Personal Support Services Agencies are licensed by the Department of Mental Health and Substance Abuse Services.
What Tennessee requires
Tennessee
Licensing agency. Since July 2022 (Public Chapter 1119), the Tennessee Health Facilities Commission — an independent agency that absorbed the Health Services and Development Agency and the Department of Health's health care facilities licensure program — licenses home health agencies and other home care organizations under Tenn. Code Ann. § 68-11-201 et seq.
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PSSA license. Agencies providing non-medical personal support (homemaker, personal care, sitter, in-home respite) license as Personal Support Services Agencies (PSSAs) through the Tennessee Department of Mental Health and Substance Abuse Services Office of Licensure under Tenn. Code Ann. Title 33 and Rule 0940-05-38, with annual renewal, $1M liability and workers' comp insurance minimums, and employee background/registry checks.
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CON for home health. Home health agencies require a Certificate of Need from the Health Facilities Commission before licensure, restricting new skilled entrants by county.
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Surveys. The Health Facilities Commission's Division of Licensure and Regulation performs initial and periodic licensure surveys and complaint investigations with plan-of-correction enforcement, and conducts Medicare certification surveys as the CMS state agency; PSSA initial inspections are handled by TDMHSAS (via desk audit) with licenses issued for up to one year.
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The federal baseline (applies in every state)
Federal
No federal home care license. There is no federal license for home care or home health agencies. Licensure is a state function: each state (and DC) decides whether and how to license home health agencies and non-medical personal care/companion agencies, so requirements vary dramatically by jurisdiction.
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Medicare certification (42 CFR Part 484). Agencies that bill Medicare for skilled home health must be certified as meeting the Medicare Conditions of Participation at 42 CFR Part 484 (patient rights, comprehensive assessment, QAPI, skilled professional services, home health aide standards, and more), on top of any state license.
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Accreditation with deemed status. Most new Medicare home health agencies obtain certification through a CMS-approved accrediting organization with deeming authority — ACHC, CHAP, or The Joint Commission — whose surveys substitute for the state agency's Medicare certification survey.
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State survey agencies enforce both. State survey agencies (usually the state health department) operate under agreements with CMS to survey Medicare-certified agencies, and most also run the state licensure survey program — initial surveys, renewal/recertification surveys, complaint investigations, and plan-of-correction enforcement per the CMS State Operations Manual.
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