In a state where barbers, manicurists, and massage therapists must be licensed, home care agencies providing nonmedical support are subject to shockingly little oversight, despite the profound vulnerability of the people who rely on them.
Massachusetts is one of only four states without a licensing process for private, nonmedical home care agencies, said Harrison Collins, director of legislative affairs for the Home Care Alliance of Massachusetts, an industry group representing about 200 agencies that provide help with the tasks of daily living, including bathing and toileting, household chores, and basic companionship.
“In many respects, it’s easier to open a home care agency than a pizza shop in the Commonwealth,” he wrote in a letter endorsing the legislation.
That may soon change.
Earlier this month, the Massachusetts House passed a bill that would create a licensing requirement and establish standards and oversight for nonmedical home care agencies. The legislation focuses on home care businesses, not individuals who work in the field, such as through the state’s personal care attendant program. It proposes worker background checks, mandatory training on skills including infection control and dementia care, transparency around the services that agencies provide and their costs, and protections for workers.
“The industry is asking for regulation,” said state Representative Thomas Stanley, a Waltham Democrat and sponsor of the bill that passed the House earlier this month. “We want to get higher quality people to take care of our loved ones.”
If passed by the Senate, the legislation would become the latest in a series of health care-related laws to address Massachusetts’ aging population and the shortage of people to care for them, including two that increased oversight for long-term care facilities and hospitals.
Well over 100,000 people work as home health or personal care aides in Massachusetts, according to 2024 data from the Bureau of Labor Statistics, many of them giving extraordinary care that’s both emotionally and physically taxing for modest pay. Their mean annual income nationally was shy of $17 an hour, the bureau reported.
Because of the lack of oversight in Massachusetts, it’s not clear how many people rely on these services. The state runs 24 regional senior services offices that provide home care to 70,000 individuals, but that doesn’t include the many thousands who get care through private agencies. A lack of oversight of those private agencies leaves the door open for unscrupulous or inexperienced operators, and families adrift in their search for competent help at home.
“Right now anybody could roll into town and they could put a shingle out and they could start hiring people and offering home care,” said Paul Lanzikos, a coordinator for the disability advocacy group Dignity Alliance Massachusetts.
Before her illness, which was diagnosed five years ago, Kirsten Hano had a thriving career as an advertising account executive and raised three sons. She started the first girls high school hockey team in Vermont, her husband said, and contributed to an inner-city girls mentoring program.
“She was always giving back,” Doug Hano said.
He works from home most of the time but relies on home care aides to help between 11 a.m. and 3 p.m.
Agency workers’ quality of care varies wildly, Doug Hano said. One worker listened to an online class on her earbuds while helping his wife eat lunch. Another left her staring at a television while the worker stared at her phone.
“If there’s somebody who’s not so great, who’s not so engaging, who doesn’t know how to keep the energy up and stay positive, she can sink into a really tough spot,” Doug Hano said of his wife.
Under the proposed legislation, agencies would need a three-year license through the state Executive Office of Health and Human Services to operate. HHS could inspect and investigate agencies, and would have the power to suspend, revoke, or refuse to renew licenses. Penalties would include a $500 daily fine until the violation is resolved.
Anyone with a 5 percent or greater ownership stake in an agency would have to be identified and provide background information, including criminal and civil findings.
An April letter from the union representing about 60,000 home care workers statewide, SEIU 1199, noted private equity has made inroads in the home care industry.
If passed, the legislation’s requirements for home care agencies would go into effect within a year.
Collins, of the Home Care Alliance, said many agencies already meet the proposed standards. But with virtually no bar to entry, a glut of businesses leaves those that spend the money on training and quality control at a disadvantage.
“They’re being undercut by agencies that skirt the rules,” Collins said. “In the end, it creates subpar care.”
There are as many as 1,500 home care agencies operating in the state, according to Representative Stanley’s office.
The legislation benefits workers, too, said Rebecca Gutman, SEIU 1199’s vice president of home care. Along with protections to ensure fair payroll practices and workers’ compensation and liability insurance, it proposes creating a reporting and tracking system for mistreatment complaints from both clients and workers.
“If there are employers out there consistently harassing the workers that come into their home, there needs to be a process for protecting that worker,” Gutman said.
While the licensing requirements would apply only to agencies, the abuse protections would benefit anyone doing home care work.
This year, Doug Hano found a home care worker whom he ranked as an 11 on a scale of one to 10.
“She knew all the ins and outs of dealing with someone with Alzheimer’s,” he said.
Then, about two months ago, her car failed. She hasn’t been able to get it fixed and is now only available for overnight care when he goes on business trips.
The agency’s replacement is good, he said, but his wife’s condition is declining, and he is concerned he may soon need more hours of daily home care support. If his current care worker isn’t able to fill those hours, he may be forced once again to search for someone he can trust with Kirsten’s wellbeing.
“It seems mind-boggling that Massachusetts, pretty progressive, wouldn’t have something…” he said, “to just make sure that there is more training, there is more vetting, there is more accountability.”
Jason Laughlin can be reached at jason.laughlin@globe.com. Follow him @jasmlaughlin.
