Adult Day Care Center: Opening a Medicaid Certified Adult Day Care Center

Return the application and other materials:

• Email thomas.rylander@dhs.wisconsin.gov

• Mailing address

  DHS Division of Quality Assurance
  Licensing, Certification and CLIA Section, ADCC Certification
  PO Box 2969
  Madison, WI 53701-2969

Please review Wis. Stat. § 49.45(47)(b) and Wis. Admin. Code § 105.14 prior to completing an application. You must submit the following certification information:

• ADCC certification application, F-03267 (Word), completed in its entirety.
• $127 fee. This fee must be paid via mailed check, even if the remainder of the application materials are being submitted electronically. Please make the check out to the Division of Quality Assurance.
• A clearly labeled floor plan showing all measurements, and clearly labeled areas that qualify as participant square footage under Wis. Admin. Code § 105.14(8)(a)2, which requires 50 sq. ft. per participant, not including passageways, bathrooms, lockers, office, storage areas, staff room, furnace rooms, and parts of rooms occupied by stationary equipment. Keep this square footage in mind as you determine your ADCC's maximum participant capacity.
• Fire inspection report.
• Submit Entity Caregiver Background Checks to the Office of Caregiver Quality (OCQ).
• Model Balance Sheet, F-62674A, showing 60 days operating funding.
• A financial reference showing that your ADCC has access to at least the amount of money needed on your Model Balance Sheet, which could be any 1 or more of the following:
  • Letter of reference from the ADCC's financial institution.
  • Bank statement.
  • Evidence of stock ownership.
  • Verification of outside employment or other income.
• Your IRS Tax ID letter.
• Organizational documents depending on your ADCC structure:
  • Corporations: Provide a copy of articles of incorporation.
  • Limited liability companies (LLCs): Provide a copy of articles of organization and operation agreement.
  • Limited liability partnerships (LLPs): Provide a copy of the partnership agreement.
• Proof of transportation insurance, if the ADCC provides transportation.
• Well water test results, if applicable.
• Program evaluation plan.
• Program description. This is a document that would be provided to potential participants and members of the general public, and needs to include:
  • Operator name.
  • Program director name.
  • Participant capacity. This capacity needs to reflect the qualifying square footage under Wis. Admin. Code § 105.14(8)(a)2, as discussed above.
  • Program goals and description.
  • Hours.
  • Limits.
  • Fee schedule.
  • Procedure for informing of changes.
  • Procedures for incident reporting.
  • Participant group and explanation, if more than one.
  • Grievance procedure.
  • Criteria for involuntary discharge.
• Participant rights document, to be provided to potential and current participants. This is often included in an ADCC's program description.

Once the application materials are accepted, a surveyor from the Acute Care Compliance Section (ACCS) will work with you to schedule and complete an announced initial visit. It is the provider's responsibility to know and understand the regulations governing adult day care centers. Additionally, the operator is responsible for the information contained in the DQA numbered memos. You may also sign-up to receive email notifications of new DQA memos, DQA Quarterly Updates, and additional health care policy-related information.

A review of your physical space is integral to the ADCC certification process. Therefore, re-application and re-survey of an ADCC's new location is required when a move occurs. Some elements of the initial application process are not required, as you are already an established ADCC in good standing.

Return the documents to:

• Email thomas.rylander@dhs.wisconsin.gov

• Mailing address

  DHS Division of Quality Assurance
  Licensing, Certification and CLIA Section, ADCC Certification
  PO Box 2969
  Madison, WI 53701-2969

You must submit the following certification information:

• A written request detailing the effective date of the move and any significant details about the location.
• A clearly labeled floor plan showing all measurements. You must clearly label areas that qualify as participant square footage under Wis. Admin. Code § 105.14(8)(a)2, which requires 50 sq. ft. per participant, not including passageways, bathrooms, lockers, office, storage areas, staff room, furnace rooms, and parts of rooms occupied by stationary equipment. Keep this square footage in mind as you determine your ADCC's maximum participant capacity.
• ADCC certification application, F-03267 (Word), completed in its entirety.
• Fire inspection report.
• $127 fee. This fee must be paid via mailed check, even if the remainder of the application materials are being submitted electronically. Please make the check out to the Division of Quality Assurance.
• Well water test results, if applicable.
• Program description reflecting any changes resulting from the move. This is a document that would be provided to potential participants and members of the general public, and needs to include:
  • Operator name.
  • Program director name.
  • Participant capacity. This capacity needs to reflect the qualifying square footage under Wis. Admin. Code § 105.14(8)(a)2, as discussed above.
  • Program goals and description.
  • Hours.
  • Limits.
  • Fee schedule.
  • Procedure for informing of changes.
  • Procedures for incident reporting.
  • Participant group and explanation, if more than one.
  • Grievance procedure.
  • Criteria for involuntary discharge.