Tennessee adult day services center license: the TDHS process and the September 2026 rule changes

Who needs a license, and who does not

Tennessee’s rule defines adult day services as services to five or more participants, for more than three hours but less than 24 hours a day, by a provider who is not related to the participants, delivered under an individualized plan of care meant to maintain or restore each participant’s capacity for self-care through medical or social services ⁠¹. An adult is anyone 18 or older ⁠¹. TDHS states the threshold plainly: centers serving five or more people must be licensed by the department ⁠².

That definition leaves three gaps worth checking before you design anything:

• Four or fewer participants, or three hours or less a day. Neither meets the definition in rule 1240-07-10-.03 ⁠¹. Do not count on staying small inside a licensed building, though: an exempt or unlicensed group operating at the same or a contiguous location as a licensed center is treated as part of the licensed group unless TDHS approves otherwise ⁠¹.
• Religious limited respite programs. T.C.A. § 71-2-402 exempts religious institutions or organizations that run a “limited respite care services program” meeting the statute’s conditions. They request the exemption through the TDHS provider portal ⁠⁵.
• Programs already licensed by another state agency. The Commissioner may decide, after consulting that agency, that its licensing adequately regulates the program and a TDHS license is unnecessary ⁠¹.

Nursing homes, hospitals, assisted-care living facilities, homes for the aged and residential hospices that want to run a day program do not get an automatic pass. A center on the premises of, and operated by, one of those facilities needs written approval from both the Tennessee Department of Health and TDHS before a license can issue, must meet every adult day licensing rule, and must keep its participant records and activities separate from the host facility’s ⁠¹. Those residential licenses are covered in the guides to the assisted-care living facility license and the home for the aged license. For how other states draw this line, see the adult day care license page.

A human services license, not a health facility license

Most Tennessee care licenses (assisted care, homes for the aged, home health) sit with the health facilities regulator. Adult day is different: it falls under T.C.A. §§ 71-2-401 et seq. and TDHS rule chapter 1240-07-10, and the program is funded through the federal Social Services Block Grant ⁠¹⁠². In practice that means your contacts are TDHS staff who also process child care applications. The pre-licensure mailbox is [email protected], the e-licensing portal is shared, and complaints go to the Child and Adult Care Complaint Hotline at 1-800-462-8261 or [email protected] ⁠²⁠³.

The rule also carries a “medical or social” model in one license. There is no separate adult day health tier: a center can offer nursing or therapy, and the application asks you to list services such as skilled nursing, physical or occupational therapy, case management and transportation, but the licensing standards are the same for every center ⁠¹⁠⁴.

The licensing sequence TDHS uses

Rule 1240-07-10-.05 requires a pre-application meeting and a director orientation; TDHS’s own page lays out the working order ⁠¹⁠³. As published on October 12, 2026:

1. Email the Pre-Licensure Unit

   Write to [email protected] to sign up for the informational orientation. Since September 22, 2026 the rule itself names the pre-licensure unit as the first contact, replacing “the local licensing office” ⁠¹⁠³.

2. Open an e-licensing account and complete pre-application training

   A Program Specialist emails instructions; you create the provider portal account, register for orientation and complete the pre-application training ⁠³. TDHS posts the pre-application training online ⁠¹¹.

3. Attend orientation/intake

   If a board governs the program, the director attends; if the applicant will not manage day to day, both the applicant and the director attend ⁠¹. Every new director must also attend a TDHS orientation on the laws and rules within six months before the license is issued ⁠¹. TDHS can waive the pre-application training in writing for someone who already completed it ⁠¹.

4. Tell TDHS you are ready and secure a location

   You complete the application in the e-licensing system only after the Program Specialist confirms you have a site ⁠³.

5. Measuring visit

   The Program Specialist measures the space for capacity, looks for hazards, and requests the State Fire and/or local fire inspection, the environmental inspection and a “Choose Safe Places” review ⁠³.

6. Inspections and background clearances

   You are responsible for passing the state fire, local fire and environmental health inspections; written approval must be in hand before a temporary license issues ⁠³. Fire, environmental and any food establishment approvals must be dated within the 60 days before approval and must reflect your capacity ⁠¹. Clearance letters are needed for everyone covered by the background check rule (below) ⁠³.

7. Pay the fee

   TDHS requests the fee only after inspections and clearance letters are received ⁠³.

8. Two walk-throughs

   The Program Specialist does the first; the second adds a Licensing Consultant and a Field Supervisor. A Program Manager approves the temporary license if all rules, documents and trainings are met ⁠³.

With the application the director or owner submits proof of education, a verifiable work history, three non-related references and the business organization documents ⁠³. The rule adds copies of your filings with the Tennessee Secretary of State, Division of Business Services, where applicable ⁠¹.

What goes on the application

Form HS-3423 (version 03-19) is more operational than most license applications ⁠⁴. Before you file, you need answers for:

• Legal organization and every owner, plus each owner’s history with any adult day agency and any child care agency they have owned, worked for or volunteered at ⁠⁴.
• Governing board members, where a board is required ⁠⁴.
• Target population and a detailed program description, whether you are accredited, meal plans and whether you participate in the Child and Adult Care Food Program ⁠⁴.
• All services, every extra fee (assessment, registration, transportation, therapy) and your rates by frequency ⁠⁴.
• Transportation plans and vehicles, including license plate numbers, and copies of all third-party contracts for programs or services ⁠⁴.
• Funding sources (private pay, Medicaid waiver, SSBG, long-term care insurance) and your general and vehicle liability policy numbers ⁠⁴.
• An hour-by-hour staffing chart showing participants and staff assigned to each group ⁠⁴.

Before granting the temporary license TDHS must also verify that the administrative structure provides for full-time management, that the director meets the qualifications, that the site passed an on-site inspection, and that no applicant, owner, director or employee was previously in ownership or management of a center cited for violations, unless TDHS finds them otherwise qualified ⁠¹.

Insurance and business structure

General liability coverage of at least $500,000 per occurrence and $500,000 general aggregate is a condition of the temporary license ⁠¹. Any vehicle the center uses or controls for participant transport must carry vehicle liability insurance ⁠¹.

For-profit centers are run by the licensed entity or individual ⁠¹. A center owned by a municipality, county or nonprofit corporation that serves 10 or more participants must have a governing board of at least four members. Since September 22, 2026 that board must meet quarterly (previously annually) with minutes showing financial review ⁠¹⁠⁹. Board members cannot have a direct or indirect interest in a contract to supply the center ⁠¹.

Every center needs written policies on admissions, discharges, fees, hours, transportation (if offered), personnel and emergencies and disasters, a written philosophy and goals, and a referral system for applicants you cannot serve, for example to the Area Agency on Aging and Disability or 211 ⁠¹. If you operate inside a church, school, senior center or health facility, a written agreement must cover your hours of use, maintenance, equipment, security and shared services ⁠¹.

Space and building requirements

• Activity space: at least 40 square feet of indoor activity space per participant, not counting bathrooms, storage or staff-only rooms ⁠¹. Licensed capacity is set by TDHS from your indoor space and staffing ratio and printed on the license ⁠¹.
• Shared space: a center on or next to a nursing home, hospital, assisted-care living facility, home for the aged or residential hospice may share dining or therapy rooms on a staggered basis, but shared rooms do not count toward the 40 square feet; programs in multi-use buildings need dedicated space meeting the 40-square-foot figure ⁠¹.
• Accessibility and rooms: program space on the ground floor or reachable by elevator, ramp or other assistive device, with room for individual and group activities, a private office, storage, special therapies, a rest area and an area to isolate ill participants with furniture that lets them recline or lie down ⁠¹.
• Toilets: two toilets for the first 15 participants (one wheelchair accessible) and one more for each additional 10; half of all toilets must be wheelchair accessible ⁠¹.
• Equipment on site: a first aid kit with specified contents, blankets, a wheelchair, a blood pressure cuff, a scale, walkers and locked drug storage ⁠¹.
• Inspections: an approved fire safety inspection, directed by the State Fire Marshal’s office, before the temporary license and before every annual license ⁠¹. The September 2026 text no longer contains the 2023 provision that excused centers inside licensed health facilities from a separate fire inspection; the environmental-inspection exemption for those centers remains ⁠¹⁠⁹. Environmental inspections are directed by the Department of Health, and new construction or major renovation must meet the standards of the Fire Prevention Division and the Department of Health ⁠¹.
• Food: you need any required Department of Health food permit and inspections ⁠¹.
• Telephone: a working telephone; the 2023 rule required a land line ⁠¹⁠⁹.

Two centers on one property are possible, but each needs its own application, fire and environmental inspections, ratios and staff, and a director may oversee no more than two sites while spending 50% of working hours at each ⁠¹.

Director qualifications

The director must meet one of five routes ⁠¹:

A certificate of attendance or correspondence or video courses do not count as a high school diploma ⁠¹. An assistant director or other designated staff member acts when the director is absent ⁠¹.

Staff, ratios and training

• Ratio: at least one direct-care staff member per eight participants, on site, with at least one more staff member during off-site activities and a plan for calling in backup staff in an emergency ⁠¹.
• Who counts: at least 75% of the people counted in the ratio must have a high school diploma or GED, at least one staff member who reads, writes and speaks English must be on site, and staff and volunteers must be 18 or older ⁠¹. High school students 14 and up may do office work or companionship under supervision but never count toward the ratio ⁠¹. Volunteers count only if they meet direct-care qualifications and background checks ⁠¹.
• CPR: at least one direct-care staff member certified in CPR and trained in first aid, the Heimlich maneuver and the center’s emergency plans must be present at all times ⁠¹.
• Training: before starting, all staff complete department-recognized training on universal precautions, fire safety, emergency plans, infection control and recognizing and reporting abuse, neglect or exploitation; the abuse training must be done within 30 days of starting; and everyone completes eight hours of annual training ⁠¹.
• Records: each employee and ratio volunteer file holds addresses for the prior 12 months, the criminal history disclosure form, the background check clearance letter, education and employment history, three verified non-relative references, a job description, an annual evaluation and training hours, kept one year after the person leaves ⁠¹.

The December 2025 rulemaking notice proposed deleting the English-speaker and 75% diploma requirements and adding a minimum of two staff on site during operating hours ⁠⁸. The version compiled by the Secretary of State effective September 22, 2026 still contains the first two requirements and does not contain the two-staff rule ⁠¹. The sources do not say why the proposals are absent from the final text, so ask TDHS whether a two-staff minimum is planned before you set your staffing.

Background checks

Owners and operators with significant contact, every employee, director and manager, and volunteers who exceed 36 hours a year and either count in the ratio or have unsupervised access must complete a disclosure form, fingerprints for TBI and FBI checks, and searches of juvenile records, the Department of Health vulnerable persons registry, the TBI sex offender registry and the Department of Children’s Services abuse registry before having unsupervised access ⁠¹. The center pays the fingerprint and TBI costs unless TDHS says otherwise, and may pass them to the applicant ⁠¹. Drivers are barred for five years after convictions such as DUI or vehicular homicide ⁠¹.

An employee who leaves one licensed adult day center can move to another without new fingerprints if the new employer files TDHS’s Notification of Transfer of Employment within 180 days of separation and the prior checks are less than five years old ⁠⁶.

Program, records, medication and transportation rules

Daily programming must include physical exercise, rest, social interaction, learning and mental stimulation; passive activities such as television may fill no more than 20% of the planned schedule ⁠¹. Restraints require a time-limited physician’s order; locked and chemical restraints are banned ⁠¹. Centers serving people with Alzheimer’s disease are also subject to T.C.A. §§ 68-11-1401 et seq. ⁠¹.

Each participant needs a pre-enrollment assessment and an individualized plan reviewed at least every three months with a written quarterly progress report; records are kept one year after disenrollment ⁠¹. Staff may give prescription medication only under the direction of the participant’s physician, and known medication errors must be reported to the family and TDHS within 24 hours ⁠¹.

If you transport participants, drivers need the license class Title 55, Chapter 50 requires, a trip log and an end-of-route walk-through of the vehicle; no one rides more than 90 minutes without a rest stop; vehicles carry an extinguisher, triangles, seat belt cutter, flashlight, first aid kit and bloodborne pathogens kit; and transport staff take TDHS annual training and, since September 2026, must be certified in first aid, CPR and Basic Life Support ⁠¹⁠¹¹.

Fees

Form HS-3423 (03-19) lists these annual fees, payable to the Treasurer, State of Tennessee (the form names a cashier’s check or money order and says the fee is non-refundable), as published on the form checked October 12, 2026 ⁠⁴:

The rule says current fees are kept on the department’s website and accepts certified, business or government check, money order or an electronic method if TDHS offers one ⁠¹. The rule points to the TDHS website for current fees, and the sources read for this guide show no fee page newer than the 2019 form; ask the Pre-Licensure Unit to confirm the amount before you pay. Centers run under a TDHS grant by a public, nonprofit or municipal body that pays an administrative fee under the grant are exempt ⁠¹.

Temporary license, annual license and renewal

The temporary license lasts up to six months (or until TDHS grants or denies the annual license, whichever is later) and can be extended up to six more if you are making substantial progress ⁠¹. During that period TDHS makes at least two visits, one unannounced, observes caregivers with participants, reviews records and completes an evaluation checklist before deciding on an annual license ⁠¹. New since September 22, 2026: an existing operator opening another location can ask TDHS to waive the temporary period, judged on its violation history, whether the current director will run the new site and whether the new site will operate like the existing one ⁠¹.

Renewal applications and fees are due at least 30 calendar days before expiration. If the license lapses, the center must stop operating immediately and start a new application ⁠¹. Licenses do not transfer to a new owner or location; a sale, lease or other transfer of control voids the license immediately, and the center must close unless the buyer has applied for and been granted a temporary license ⁠¹.

Licensed centers are inspected throughout the year and on complaints ⁠⁷. Serious incidents, including injuries needing more than first aid, law-enforcement or 911 calls about serious or life-threatening incidents (not routine medical calls) and vehicle accidents or traffic citations with participants aboard, must be reported to TDHS within 24 hours, and fire drills must be held monthly ⁠¹. Violations lead to a corrective action plan due in 10 business days, probation of 30 to 60 days, or revocation on 60 days’ notice, and TDHS can summarily suspend a license when participants are at risk ⁠¹.

TennCare and other payers

TennCare’s CHOICES program covers adult day care only when delivered in an adult day care facility permanently licensed by DHS, under an individualized plan of care by an unrelated provider; assistance and supervision are part of the benefit and cannot be billed separately ⁠¹⁰. CHOICES Group 2 and Group 3 members are each covered for up to 2,080 hours of adult day care per calendar year ⁠¹⁰. The TDHS application adds that any center wishing to serve Medicaid recipients, now or later, must be found compliant with the federal Home and Community-Based Services settings rules before it can be reimbursed ⁠⁴. The TennCare rule says all CHOICES services must be authorized by the member’s managed care organization, but the official sources read here do not describe the MCO credentialing steps for adult day providers; ask TDHS and the TennCare MCOs how a licensed center contracts and enrolls ⁠¹⁰.

What changed in 2026

Amendments filed June 24, 2026 took effect September 22, 2026, after a public hearing on February 12, 2026 ⁠¹⁠⁷. Compared with the January 2023 text ⁠⁹, the changes a new operator will notice are:

• First contact moved to the TDHS pre-licensure unit ⁠¹.
• Temporary license now “up to” six months, with a waiver option for existing operators’ new sites ⁠¹.
• Governing boards meet quarterly instead of annually ⁠¹.
• Fire drills monthly instead of quarterly ⁠¹.
• Serious incidents and medication errors reported within 24 hours instead of the same day ⁠¹.
• Transport staff must hold first aid, CPR and Basic Life Support certification ⁠¹.
• The separate fire-inspection exemption for centers inside licensed health facilities is gone, and any working phone replaces the land line requirement ⁠¹⁠⁹.

Before you sign a lease, ask TDHS three things the published sources leave open: the fee currently charged, whether the two-staff minimum will return, and how TennCare managed care organizations contract with a newly licensed center.

Sources

1. 1
   Tennessee Secretary of State, Rules of the Tennessee Department of Human Services, Chapter 1240-07-10: Adult Day Services Standards (September 2026 revision) Checked 12 Oct 2026 · Back to text ↑
2. 2
   Tennessee Department of Human Services, Adult Day Services Checked 12 Oct 2026 · Back to text ↑
3. 3
   Tennessee Department of Human Services, Learn More About Adult Day Services (How to Become a Licensed Adult Day Services Center) Checked 12 Oct 2026 · Back to text ↑
4. 4
   Tennessee Department of Human Services, Application for a License to Operate an Adult Day Services Agency, Form HS-3423 (03-19) Checked 12 Oct 2026 · Back to text ↑
5. 5
   Tennessee Department of Human Services, Exception for Limited Respite Care Services Checked 12 Oct 2026 · Back to text ↑
6. 6
   Tennessee Department of Human Services, Criminal Background Check Process for Adult Day Service Employees Checked 12 Oct 2026 · Back to text ↑
7. 7
   Tennessee Department of Human Services, Adult Day Services Rules and Regulations Checked 12 Oct 2026 · Back to text ↑
8. 8
   Tennessee Secretary of State, Notice of Rulemaking Hearing, Chapter 1240-07-10 (filed December 30, 2025) Checked 12 Oct 2026 · Back to text ↑
9. 9
   Tennessee Secretary of State, Chapter 1240-07-10: Adult Day Services Standards (January 2023 revision) Checked 12 Oct 2026 · Back to text ↑
10. 10
    Tennessee Secretary of State, Rules of the Tennessee Department of Finance and Administration, Chapter 1200-13-01: TennCare Long-Term Care Programs (October 2025 revision) Checked 12 Oct 2026 · Back to text ↑
11. 11
    Tennessee Department of Human Services, Adult Day Services Training Checked 12 Oct 2026 · Back to text ↑

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