If you run a home care agency in Massachusetts, the odds are that no inspector has ever walked through your door.
On November 4 that starts to change. A new law puts every agency under a license for the first time. In July, a state senator said the quiet part out loud: "We don't even know how many such agencies there are."
We buy and run care businesses, so we went and counted. Then we read every inspection report on the public record, and looked at the eight states that went first.
Here is what the state will see when it starts looking, and what you can do before it does.
What the state is about to find
The state's own list has 595 homemaker and personal care providers. Our count of named agencies runs to 2,010. The payroll records sit in between: 1,012 home care businesses with employees and 44,552 jobs, on the 2025 annual average.
Who owns them is the next question. The answer, for most of them, is no group at all.
And they are not spread evenly.
Our take
The license will not shrink the market. It will reveal it. Most of the agencies on the federal registry first registered in the last five years, and most sit on no list the state keeps. The rules get written around whoever is counted first.
What happened in the states that went first
Thirty-one of the fifty states and DC license non-medical home care, Massachusetts included. Eight did it before; their record is the best guide to the next two years.
Getting from the law to a working license took years, not months.
The application itself was the same everywhere.
Our take
In most states, the license was won in the file, not at the inspection. Every application asked for the same core records, and the agencies that had them ready kept operating while the state caught up. The file you build this winter is the license.
What an inspector marks down
Most Massachusetts home care agencies have no public inspection record, and most of the ones that are inspected keep their reports private. Only the 287 Medicare-certified agencies are inspected today, and about four in five of those by a private accreditor whose reports are not published. The 309 public state surveys show what inspectors have already cited.
Only 8 of the 309 surveys were at condition level. The most-cited items are missed visits in the plan of care, the physician not being told, and infection prevention. After a recertification survey with deficiencies, the next one also had deficiencies in 23 of 41 cases, 56%.
The Medicare star ratings do not fill the gap either. They score patient outcomes and surveys, not inspections, and more than half of the agencies lack enough Medicare patients to be rated.
Our take
The inspector checks the file, not the care. Most of the list is paperwork and follow-through in Massachusetts today and in Minnesota ten years in, and a small agency with good caregivers and a thin file is the one most at risk. We think that daily record-keeping will increasingly be done by software built for one agency, and that is where we are putting our own effort.
If you own an independent agency, this is your moment
Three forces are arriving at once, and we think all three favor the owner who moves first.
The law. From November, the state starts licensing. Every agency will need a license by a date the state sets later, and every change of ownership gets a suitability review.
More agencies, not more caregivers. About a quarter more home care businesses than in 2019, and fewer people working in them. Of the Medicare agencies that report figures for both years, 53 of 81 grew revenue in 2024 and 14 shrank by a tenth or more.
Buyers have been here since 2016. Most Massachusetts agencies are independent. Of the 38 deals with a known buyer, 29 went to investor-backed groups, franchise owners or public companies, and two to long-term owners.
Whatever you decide to do, keep the license or sell, the steps are the same, and in this order.
1. Get your books in order. Client contracts, staff contracts and background checks, visit records, the plan of care. The file gets read before anyone meets a caregiver, and three different readers are about to open it.
2. Build the private-pay side. Medicare is where today's inspections and star ratings apply, and where the thin margins show up.
3. Show growth. Growth is the one number nobody can audit into existence. Write it down month by month: hours delivered, clients served, the private-pay share, the caregivers who stayed. We think that page, a year of it, is the one a buyer reads first, and the state will not be far behind.
Our take
An agency that depends on Medicare lives on a rate it does not set, and we pay less for it. The agency we pay for has a file that passes, a year of rising private-pay hours, and a name written down for the day the owner is not there. One in three Medicare-certified agencies has a single owner who also manages it, so that last name is the first thing we look at.
Closing thoughts
Until now, Massachusetts home care grew without a license, and most of it is what it should be: independent owners, local names, caregivers who show up. The license changes who gets to see it, not what it is. Our advice is the same whether you keep the agency or sell it: get the file ready, build the private-pay side, and write down who takes over. If you want to compare notes on your own numbers, Jim's email is in the box below.