Adult Day Care Regulations in Wisconsin

Who regulates adult day care in Wisconsin

The Wisconsin Department of Health Services (DHS) certifies adult day care centers (ADCCs) through its Division of Quality Assurance (DQA). The standards are in Wis. Admin. Code § DHS 105.14, part of the DHS provider certification chapter, and DQA also points operators to Wis. Stat. § 49.45(47)(b).

According to DQA, certification is voluntary unless you plan to serve people who receive Medicaid waiver funding from a county. DHS 105.14 also bars reimbursement under s. 49.45(7)(b), Stats., for services to participants unless the center is certified. Ask each Family Care MCO whether it requires DQA certification before contracting.

Types of adult day programs in Wisconsin

DHS 105.14 defines an adult day care center as an entity that provides services for part of a day in a group setting to adults who need an enriched health, supportive or social experience and who may need help with activities of daily living, supervision or protection. The rule sets a stricter staffing ratio for severely impaired participants, defined as people who cannot perform three or more activities of daily living without help.

How to get certified in Wisconsin

DQA's opening and certifying page lists these steps:

1. Review Wis. Stat. § 49.45(47)(b) and DHS 105.14, and plan capacity around the space requirement.
2. Apply through the DQA Provider Portal and pay the application fee.
3. Submit a labeled floor plan, a fire inspection report, background checks for owners and operators, a model balance sheet showing 60 days of operating funds, a financial reference, tax and organizational documents, transportation insurance if you transport participants, a program evaluation plan, a program description and a participant rights document.
4. After DQA accepts your materials, a surveyor from the Acute Care Compliance Section schedules an announced initial visit.

DHS must find the applicant fit and qualified. A center may not be located on land zoned for industrial or manufacturing use, and certification stays valid until suspended or revoked. Certified centers use the portal for required reports and fees and to report changes such as ownership, relocation, capacity or program director.

Key requirements

DHS 105.14, effective December 1, 2021, requires:

• Staffing: at least one qualified caregiver on the premises whenever participants are present, with a minimum of one caregiver for every 8 non-severely impaired participants and one for every 4 severely impaired participants.
• Program director: at least 21, with an associate degree or higher in a health care field or at least 2 years of related experience. A qualified caregiver at least 18 is in charge when the director is absent.
• Staff: caregivers at least 16, orientation before starting work, training within 90 days of hire (including first aid and fire extinguisher use) and at least 10 hours of continuing education per calendar year.
• Medications: a written policy, practitioner orders for caregiver-administered medications, and an RN or LPN for certain routes such as injections, unless delegated as the rule allows.
• Space: at least 50 square feet of usable floor space per participant, not counting passageways, bathrooms, offices and storage, and a temperature of at least 70 degrees.
• Meals: a meal providing at least one-third of daily nutritional needs for participants present five or more hours, plus a nutritious snack.
• Safety: a written emergency plan, quarterly fire drills, annual tornado drills and monthly smoke detector tests.
• Reporting: written reports within 3 working days for events such as a missing participant or a serious injury needing hospital care, and reports of certain deaths within 3 days.

DHS may inspect centers, including unannounced visits, and can issue notices of violation, require plans of correction, or suspend or revoke certification.

Medicaid funding for adult day in Wisconsin

Family Care is Wisconsin's Medicaid long-term care program for frail elders and adults with disabilities who are at least 18 and functionally eligible. Members enroll in a managed care organization (MCO), and DHS pays MCOs a monthly amount for each member. Adult day care is part of the Family Care benefit package, and MCO care teams must approve all services before a member receives them.

DQA also notes that participants may get Medicaid waiver funding through county departments of health and human services. Centers serving people with county waiver funding must be certified.

Billing basics

For Family Care members, work with the member's MCO, which must approve services in advance. The DHS sources reviewed for this guide do not list adult day procedure codes or a statewide claim format.

Wisconsin requires electronic visit verification (EVV) for personal care, supportive home care and home health services, including in Family Care, Family Care Partnership and IRIS. Adult day care codes are not on DHS's EVV service code list.

Other ways centers are paid

Enrolled veterans who meet VA eligibility and clinical criteria can get Adult Day Health Care through the VA, which may be provided at VA medical centers, State Veterans Homes or community organizations.

Official resources

• DHS Division of Quality Assurance: Adult Day Care Centers
• DQA: Opening and Certifying an Adult Day Care Center
• Wis. Admin. Code § DHS 105.14: Adult day care centers
• Family Care Benefit Package
• Wisconsin Electronic Visit Verification

Frequently asked questions

Do I need a license to open an adult day center in Wisconsin?

Wisconsin's adult day rule, DHS 105.14, is a certification rule. DQA says certification is voluntary unless you plan to serve people who receive Medicaid waiver funding from a county, and DHS 105.14 ties reimbursement under s. 49.45(7)(b), Stats., to certification. Ask each Family Care MCO whether it requires DQA certification before contracting.

Does Wisconsin Medicaid pay for adult day care?

Yes. Adult day care is in the Family Care benefit package, delivered through managed care organizations, and participants may also have county Medicaid waiver funding.

Who inspects adult day centers in Wisconsin?

DHS's Division of Quality Assurance. A surveyor from its Acute Care Compliance Section makes an announced initial visit, and DHS may inspect certified centers, including unannounced visits.

What staffing ratio applies to adult day in Wisconsin?

At least one caregiver for every 8 participants who are not severely impaired and one for every 4 severely impaired participants, with at least one qualified caregiver on site whenever participants are present.