Nebraska adult day service license: 175 NAC 5, fees, building sign-offs and Medicaid waiver work

A small field with a light rulebook

Nebraska licenses very few adult day programs. The DHHS roster updated September 15, 2026 lists 20 licensed adult day services statewide ⁠⁶. The chapter that governs them, 175 NAC 5, was rewritten and took effect March 20, 2024 ⁠²⁠¹⁰. The rewrite moved most application, inspection and building rules into the general chapter for all health care facilities, 175 NAC 1 ⁠³. Chapter 5 now holds only adult-day-specific items: settings, fees, a few construction and physical plant rules, and the standards of operation ⁠².

Two practical results for a founder:

• The rules contain no staff-to-participant ratio, no administrator education requirement and no minimum square footage per participant. You must show that staffing is “sufficient to meet the consumers’ needs” ⁠², and DHHS judges that against your own program description during the inspection.
• The DHHS Adult Day Service web page still cites section numbers from the older 2008 chapter, such as 175 NAC 5-003.01 and 5-007 ⁠⁴. In a few places it gives older requirements than the 2024 rules; the notice section below covers one. Where they conflict, this guide follows the rule text.

Who needs the license

State law defines an adult day service as a person or entity that provides “care and an array of social, medical, or other support services” for less than 24 consecutive hours in a community-based group program to four or more persons who need those services because of age or functional impairment ⁠¹. “Community-based” means a set location outside the person’s home ⁠². “Functional impairment” covers physical conditions such as loss of mobility, sensory loss or incontinence, and mental or emotional ones such as social isolation, depression or behavioral disorders ⁠².

The rules recognize two settings ⁠²:

• Free-standing adult day service. A license is required when four or more people receive adult day services at a location not licensed as another type of health care facility.
• Adult day service inside a licensed health care facility. A nursing facility or other licensed facility that serves four or more people who do not live there needs a separate adult day license. It also needs separate, identifiable space for adult day activities during program hours.

Chapter 5 does not apply when a licensed facility provides day services only to its own residents or consumers ⁠². A program that never has more than three people at once falls below the statutory threshold ⁠¹. The statute also excludes community-based waiver services provided by an entity certified as a specialized program under the Developmental Disabilities Services Act, and PACE centers ⁠¹.

If your plan is really overnight or residential care, look at the Nebraska assisted living facility license. If your services happen in clients’ homes, see the Nebraska home health agency license. Title 175 also has separate chapters for children’s day health services (Chapter 6) and respite care services (Chapter 15) ⁠¹⁰. A day program for children belongs under child care licensing; see the child care center pages.

Choosing and documenting the building

The building paperwork is where most of the lead time goes. 175 NAC 1 makes the initial application incomplete until these documents are attached ⁠³:

1. Schematic plans. A basic diagram of the facility.
2. State Fire Marshal approval. Documentation approving occupancy and operation, issued by the State Fire Marshal or its delegated authority.
3. A current zoning permit.
4. Secretary of State registration, if a foreign (out-of-state) corporation operates the program.
5. Proof of structural safety. What this takes depends on the building:
   • If you built, enlarged or altered the structure: an architect or engineer certification, a detailed project description and a completion certificate.
   • If you made no construction or structural changes: either an operational permit from the local building authority, or a signed and dated statement from a Nebraska-licensed architect or engineer that the building is structurally safe for use and occupancy.

The Fire Marshal approval also caps your census. You may not serve more people at one time than your licensed capacity or the Fire Marshal’s maximum occupancy, whichever is lower ⁠³.

If you are building or altering

“New construction” means enlarging, altering or building a structure from the ground up. Remodeling is excluded: repair or replacement that does not move wiring, plumbing, gas, heating or cooling counts as remodeling ⁠³.

For new construction, you may not begin work until DHHS gives written approval. You may not serve anyone in the space until DHHS approves the finished work in writing and issues the license ⁠³. Before work starts, send DHHS ⁠³:

• A project description: purpose and use of the area, street address, contacts and expected completion date.
• A construction risk assessment, if the work happens in space consumers already use.
• Certification from a Nebraska-licensed architect or engineer that the plans meet the rules.

When the work is done, you submit a completion certificate. It must include the architect’s or engineer’s name and license number, inspections by qualified inspectors with jurisdiction, and Fire Marshal occupancy approval ⁠³.

Chapter 5 adds two design rules for new construction ⁠²:

• Toilet rooms must be no more than 40 feet from program and activity areas.
• If you do laundry on site, you need a conveniently located sink for soaking and hand-washing laundry.

You can ask in writing for a waiver of any physical plant requirement that is not set by statute, under Neb. Rev. Stat. 71-439, using a DHHS form ⁠³.

Physical plant rules that apply to every site

Source: 175 NAC 5-007 ⁠².

Sharing a building

Many small operators look at space inside a church, senior center or existing care facility. If the adult day service sits inside a licensed health care facility or shares space with another entity, it needs ⁠²:

• A unique physical address, so mail is secure.
• A separate entrance.
• Its own records, kept at the licensed address.

175 NAC 1 adds conditions for sharing space ⁠³:

• Each entity’s space must be clearly identified.
• Records may not be shared.
• Staff and administration must be separate; one person cannot be on duty in both entities at the same time.
• The two entities cannot use the same space for care at the same time.

Staffing, screening and training

Here the 2024 rules set duties rather than numbers.

Administrator. The licensee designates an administrator and puts the role’s duties, qualifications and responsibilities in writing ⁠². In a free-standing site, the administrator or an “equally qualified back-up administrator” must be on site during all hours of operation ⁠². The administrator’s written duties include ⁠²:

• Keeping enough trained staff to carry out each participant’s agreement and service plan.
• Running orientation and in-service education.
• Reviewing incidents and complaints.
• Setting up procedures to report abuse, neglect or exploitation under the Adult Protective Services Act (Neb. Rev. Stat. 28-372), or under 28-711 for anyone under 18.

Before anyone works with participants, the licensee must keep evidence of the following for each direct care staff member ⁠²:

• A pre-employment criminal background check through a government law enforcement agency or a private background firm.
• Checks of four Nebraska registries: the Nurse Aide Registry, the Adult Protective Services Central Registry, the Central Registry of Child Protection Cases, and the Sex Offender Registry.
• A health screening before client contact. The licensee may also require a physical exam.

You may not employ anyone listed on the Sex Offender Registry, or anyone with a Nurse Aide Registry finding of consumer abuse, neglect or misappropriation. For other findings, you decide and you document why the hire does not threaten participants or their property. You also decide whether someone can start before results come back ⁠².

Orientation must come before staff take direct responsibility for care. It covers 10 required topics, including consumer rights, each participant’s service plan, infection control, emergency procedures and advance directives, abuse reporting and disaster plans. After that, ongoing in-services are logged by date, topic and attendees ⁠².

Medications. You have three options ⁠²:

• Participants self-administer, once you determine in writing that they can do so safely.
• A licensed health care professional gives medications within their scope of practice.
• Unlicensed staff provide medications, but only if they are registered medication aides under the Medication Aide Act (Neb. Rev. Stat. 71-6718 to 71-6742) and 172 NAC 95 and 96.

In every case, medications are kept locked, only designated staff have access, and you keep an individual administration record for each participant ⁠².

If you plan to bill the Medicaid waiver, it adds staffing duties of its own; see the payment section below ⁠⁸.

Policies DHHS will ask to see at the inspection

According to DHHS, the administrator and back-up administrator must show at the inspection how the program will comply. They do this with documents written for your program: organizational charts, job descriptions, policies, procedures and forms ⁠⁴. The rules require policies to carry effective and revision dates. You must keep inactive versions for seven years ⁠².

Have these written before you ask for the inspection:

• Program description ⁠². It must be available to the public and cover:
  • your goals;
  • hours and days of operation;
  • the people you will serve (age, sex, care needs);
  • staff makeup and qualifications;
  • how you handle abuse allegations;
  • planned activities;
  • your emergency plan;
  • admission and discharge criteria, and the assessment process.
• Admission and discharge criteria, plus a template for the agreement of participation you negotiate with each participant ⁠².
• Service plan format addressing health, psychosocial and functional needs. It must be completed after an assessment by qualified staff and before services begin ⁠².
• Consumer rights policies, including freedom from chemical and physical restraints ⁠².
• Medication policies, including self-administration, error reporting and disposal ⁠².
• Food service and menus, planned on the Food Guide Pyramid or an equivalent, if you serve meals ⁠².
• The programs 175 NAC 1 requires of every licensee ⁠³:
  • a quality assurance and improvement program (results recorded quarterly and reported to the governing authority annually);
  • an infection control program;
  • a disaster preparedness program;
  • a complaint and grievance policy.

The application, in order

1. Secure a site that can pass the building paperwork. Get zoning, Fire Marshal occupancy approval, and the structural statement or local operational permit. If you plan construction, get DHHS approval before work begins ⁠³.
2. Complete the paper application. DHHS says the application “must be printed, completed, signed, and mailed” ⁠⁴. The form asks for ⁠⁵:
   • licensed capacity and planned occupancy date;
   • whether the program is free-standing or inside a licensed facility, and what type of facility;
   • legal owner and business organization;
   • federal EIN, unless you are an individual;
   • profit or non-profit status.
3. Get the right signatures. Neb. Rev. Stat. 71-433, quoted on the form, requires ⁠⁵:
   • the owner, for an individual or partnership;
   • two members, for an LLC;
   • two officers, for a corporation;
   • the head of the governmental unit, for a public program.
4. Attach the documents and the fee. Include lawful-presence documentation under Neb. Rev. Stat. 4-108 to 4-111, which 175 NAC 1 requires of every applicant ⁠³. An application counts as complete only with all information, the attestation, signatures, fees and documentation ⁠³. Mail it to DHHS Licensure Unit, Attn: Adult Day Service, PO Box 94669, Lincoln NE 68509-4669 ⁠⁴.
5. Tell DHHS when you are ready. DHHS schedules the announced initial inspection only after it has a complete application and your written notice of the date you will be ready ⁠³⁠⁴. You should be ready to operate but not operating ⁠⁴.
6. Pass the on-site inspection. DHHS’s page says it has 30 working days after a complete application to inspect, unless you ask for a later date ⁠⁴. Staff check your operations and physical plant against the rules ⁠⁴.
7. Open only after the license is issued. The license covers only the premises and owners named on it ⁠⁴.

The Office of Outpatient and In-Home Care Services takes questions at (402) 471-4967 or [email protected] ⁠⁴.

Fees

Source: 175 NAC 5-003.02 for the license fees ⁠²; DHHS Adult Day Service page for the duplicate and refund items ⁠⁴.

Because every license expires July 31 ⁠², a license issued in spring will be up for renewal within months. Neither 175 NAC 5 nor the DHHS page says whether the initial fee is prorated for a license issued late in the licensing year, so ask the Licensure Unit before you file.

Renewal, inspections and changes

Renewal. DHHS mails an expiration notice and renewal application. You return it with owner signatures and the fee before July 31 ⁠²⁠⁴. For a renewal form, call (402) 471-4967 ⁠⁴. If you miss the date, you have 90 days to ask in writing for reinstatement. The program may not operate in the meantime ⁠³.

Inspections after licensure. DHHS may make unannounced compliance inspections at any time, including when five years have passed without one ⁠³. Your license, most recent inspection report and any disciplinary notices in effect must be available to anyone who asks. The license must be displayed on site ⁠³.

Notices to DHHS. You must notify DHHS:

• 30 working days ahead, in writing, before you increase capacity, change the building, change location or change how the building is used ⁠².
• 30 calendar days before the program is sold, leased, discontinued or moved ⁠³.
• Within 24 hours of ⁠³:
  • suspected abuse, neglect or exploitation;
  • a participant death by suicide, violence, drowning, or restraint or seclusion;
  • a participant who needs supervision leaving without staff knowledge;
  • a fire;
  • disaster damage that affects participants.

The DHHS web page still gives 10 days’ notice for a sale, lease or move ⁠⁴. That figure comes from the older rule; plan on the 30 days in 175 NAC 1.

Ownership changes. A change of ownership or premises ends the license. A new owner on the same premises does not need a new inspection. A move to new premises does ⁠².

Records. Participant records must be kept at least seven years from each service date ⁠³.

How Nebraska adult day programs get paid

Medicare. DHHS states that Medicare certification is not available for adult day services ⁠⁴.

Medicaid waivers. The public payer is Nebraska Medicaid’s home and community-based Aged and Disabled (AD) Waiver, and the TBI waiver for brain injury. Both pay for “Adult Day Health” in a licensed setting ⁠⁷⁠⁸. A participant must:

• be on Medicaid;
• have a disability or be over 65;
• be 18 or older (19 in some situations) ⁠⁷;
• meet nursing facility level of care;
• have a Service Coordinator decide adult day is needed ⁠⁷.

According to the DHHS service summary dated July 2026 ⁠⁸:

• Rates. DHHS sets one statewide rate. A day of six hours or more (and under 24) is billed at the daily rate. Shorter days can be billed hourly as the person-centered plan specifies. A participant who leaves early for an unplanned need counts as a full day.
• What the service excludes. It does not include physical, occupational or speech therapy. Transportation is a separate waiver service. A participant cannot receive adult day at the same time as waiver personal care, companion, respite or several other services.
• Provider requirements.
  • You must be an enrolled Medicaid provider.
  • You must have a licensed nurse on staff or under contract. The nurse does health assessments, the nursing component and personal care training, and supervises help with daily living activities.
  • Staff and volunteers must complete criminal history screening, including Nebraska Data Exchange Network (NDEN) screening, before contact with participants.
  • Staff need training in abuse, neglect and exploitation, reporting law, and CPR and first aid.
  • You must document at least annually that the site meets the federal HCBS Final Settings Rule.
  • You need the computer access to use the state’s web-based case management system.
• Relatives. A relative or guardian can provide adult day only as an employee or owner of a licensed adult day agency. If the owner is the participant’s relative, another employee must give that participant direct care.

Medicaid enrollment. Providers must be licensed to enroll with Nebraska Medicaid, and current providers revalidate every five years ⁠⁹. Institutional and agency providers pay a CMS-set application fee unless they are already enrolled in Medicare or have paid it to Medicare or another state’s Medicaid program; the DHHS page lists $709 for 2024 ⁠⁹. CMS announced $750.00 for applications submitted from January 1 through December 31, 2026 ⁠¹¹.

What changed and what to watch

• March 20, 2024: the rewritten 175 NAC 5 took effect ⁠²⁠¹⁰. It shortened the chapter and moved application, inspection and construction procedure to 175 NAC 1.
• January 20, 2025: the current 175 NAC 1 took effect ⁠³. Its documentation list (Fire Marshal approval, zoning permit, structural statement) and its 30-calendar-day sale notice now apply to adult day applicants.
• DHHS page vs. rules: the DHHS Adult Day Service page, checked October 12, 2026, still cites 2008 section numbers ⁠⁴. Read the rule text alongside it, and confirm anything that looks inconsistent with the Licensure Unit.
• The application form in use is dated January 5, 2016 ⁠⁵. It predates both rewrites, so expect DHHS to ask for the 175 NAC 1 attachments even though the form does not list them.

More states’ rules for this business type are compared at /licenses/adult-day/.

Sources

1. 1
   Nebraska Legislature, Neb. Rev. Stat. 71-404: Adult day service, defined Checked 12 Oct 2026 · Back to text ↑
2. 2
   Nebraska Secretary of State, Rules and Regulations, 175 NAC 5: Adult Day Service (effective March 20, 2024) Checked 12 Oct 2026 · Back to text ↑
3. 3
   Nebraska Secretary of State, Rules and Regulations, 175 NAC 1: General Facility and Services Regulations (effective January 20, 2025) Checked 12 Oct 2026 · Back to text ↑
4. 4
   Nebraska DHHS, Division of Public Health, Licensure Unit, Adult Day Service Checked 12 Oct 2026 · Back to text ↑
5. 5
   Nebraska DHHS, Licensure Unit, Adult Day Service Licensure Application (revised 1-5-2016) Checked 12 Oct 2026 · Back to text ↑
6. 6
   Nebraska DHHS, Licensure Unit, Roster: Nebraska Adult Day Services (updated 9/15/2026) Checked 12 Oct 2026 · Back to text ↑
7. 7
   Nebraska DHHS, Division of Medicaid and Long-Term Care, Services on the Aged and Disabled Waiver Checked 12 Oct 2026 · Back to text ↑
8. 8
   Nebraska DHHS, Division of Disability and Aging, AD/TBI Waivers Service Summary: Adult Day Health (July 2026) Checked 12 Oct 2026 · Back to text ↑
9. 9
   Nebraska DHHS, Medicaid Provider Screening and Enrollment Requirements Checked 12 Oct 2026 · Back to text ↑
10. 10
    Nebraska DHHS, Title 175: Health Care Facilities and Services Licensure (chapter index) Checked 12 Oct 2026 · Back to text ↑
11. 11
    Federal Register, Centers for Medicare & Medicaid Services, Medicare, Medicaid, and CHIP Programs; Provider Enrollment Application Fee Amount for Calendar Year 2026 Checked 12 Oct 2026 · Back to text ↑

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