Opening a General Health Care Facility

Certificate of Need

The procedure for opening a Medicare/Medicaid health care facility in Hawaii includes obtaining an approved Certificate of Need (CON) from the State Health Planning and Development Agency (SHPDA) (  If the applicant is not interested in pursuing federal certification, SHPDA will issue a letter to the applicant indicating a CON is not needed.

State License Procedure

The applicant should submit a copy of SHPDA’s response (an approved CON, or letter indicating that a CON is not necessary) along with a written request for licensure to the Hawaii State Department of Health, Office of Health Care Assurance, 601 Kamokila Boulevard, Room 395, Kapolei, Hawaii  96707.  The Office of Health Care Assurance will respond with a written acknowledgement of the application for licensure.

Applicants should be able to meet all applicable licensing requirements (have written policies and procedures, qualified staff, etc.) by reviewing applicable regulations available on the Office of Health Care Assurance website.

The following policies and procedures should be submitted for our review prior to an initial onsite survey.  The submitted information will be returned to the facility at the time of the survey.

  1. Copy of your table of contents from your agency’s policy and procedure manual and your agency’s policy and procedure manual including the following:  Governing Body, Personnel, Patient Care, Emergency and Disaster Plan, Infection Control, In-service Training, Medical Records, and Overall Facility Program Evaluation Plan
  2.  Contracts for services not provided through salaried employees
  3.  Licenses/credentials for facility and personnel
  4.  Legal name and tax identification number, and DBA
  5.  Physical location address, phone, and fax number of the agency
  6.  Copy of the agency’s days and hours of operation
  7.  Fire inspection and building permits and floor plan
  8.  Name, address, phone, fax number, and email address of the administrator

When the documents are found to be acceptable, an initial on-site survey will be arranged. Due to existing contractual obligations, the Office of Health Care Assurance may not be able to schedule on-site surveys for several months from the time of the request.

A license will be issued to the facility when the onsite survey shows the facility is meeting applicable license requirements. A licensed facility can then admit patients with the understanding that they are cannot claim Medicare/Medicaid reimbursement until they are Medicare/ Medicaid certified.

Medicare/Medicaid Certification Procedure

The provider may voluntarily elect to participate in the Medicare/Medicaid certification program by following the directions on these websites:

When our office is notified by the Medicare fiscal intermediary (FI) that the facility is approved, our office will perform an unannounced initial certification survey. The goal of the Medicare survey and certification process is to determine whether a provider/supplier has systems in place that will provide all services necessary to meet certification requirements. A Medicare survey will be scheduled only after a provider has admitted a sufficient number of clients and demonstrated that they can provide these services. Our surveyors will use judgment based on variables such as size of the facility, client population of the geographical area, etc. when determining the number of admissions/records that are needed to indicate a fully operational status.

The initial survey is unannounced and a one step process with no revisits.  If the survey results in a denial, the initial application process starts anew.  Although our office will attempt to accommodate all requests for initial certification surveys in a timely manner, the State Survey Agency must do so according to national workload priorities as follows:

  1. Recertification surveys and associated revisits of nursing homes and Intermediate Care Facilities for the Mentally Retarded
  2. Recertification surveys of home health agencies
  3. Complaint investigations
  4. Validation surveys of accredited hospitals
  5. Recertification and associated revisits of non long-term care facilities
  6. Initial certification surveys

Deemed Accreditation

Providers that have the option of attaining accreditation that conveys deemed Medicare status conducted by a CMS-approved accreditation organization (in lieu of Medicare surveys by CMS or States) are advised to take this route. Deemed accreditation is likely to be the fastest route to certification.


Rev. 2/15