What is Accreditation? Answers to the top 5 accreditation questions around accreditation of Senior Living Communities.

1. What is accreditation of senior living communities and what is the difference between accreditation and licensing?

There are three levels of recognition that a community or long-term care provider may obtain. Licensure is a state-mandated requirement. Certification and Accreditation are both technically voluntary, but certification is, in practice, required. A provider must be certified to receive payments for resident services from  Medicare or Medicaid.

Licensure for senior housing communities is granted by the state. The state licenses are typically limited to the senior community’s nursing center and food service (commercial kitchen). The states vary on their level of regulation and licensure procedures. The appropriate licenses are required for a provider to operate.

Certification is voluntary. Certification is granted to an individual provider, facility, institution or business entity. Unlike licensure, one does not have to be certified in order to operate or practice. But a facility must be certified to receive payment from Medicare or Medicaid. Uncertified facilities are limited to private pay only and cannot receive direct reimbursement from Medicare and Medicaid. https://www.cms.gov/medicare/provider-enrollment-and-certification/certificationandcomplianc/nhs.html

Certification is governed by federal law (as both programs are funded in whole or in part by federal dollars). But it is the states that administer certification and perform the required inspections. Consumers relying on Medicaid or Medicare want certified facilities. Certification makes using your Medicare and Medicaid benefits easier. Regulators can accept accreditation in lieu of certification, so-called “deemed” compliance.

Accreditation, like certification, is also voluntary. A senior living community receives accreditation from a non-governmental or self-regulatory organization. (So-called NGOs or SROs in industry speak.) Accreditation requires passing established qualifications or standards. Accredited facilities undergo periodic evaluations and inspections to assure they’re up to standard. What is accreditation? It’s recognition by experts that a facility meets the highest industry standards.

Credential Recipient Credentialing Body Participation
Individual or Provider
State Agency
Individual or Provider
State Agency
Provider or Program
Joint Commission or CARF
(NGO or SRO)



2. What agencies accredit senior living communities and where can I find these ratings?

The Joint Commission. About 5% of all nursing homes are accredited by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO or Joint Commission). The Joint Commission is the leading healthcare self-regulatory accreditation agency having begun with hospitals way back in 1951. It was originally The Joint Commission on Accreditation of Hospitals (JCAH). The Joint Commission broadened its focus beyond the hospitals to include other health delivery settings including nursing homes or long-term care facilities and shortened its name over time. www.jointcommission.org There were as of April 2015, 711 Joint Commission accredited nursing homes and 14,926 nursing homes not accredited by The Joint Commission (JCAHO).

It’s important to note that The Joint Commission only examines the nursing center portion of a Continuing Care Retirement Community (CCRC). The Joint Commission excludes anything to do with independent living, assisted living or other programs of a full-spectrum senior living community. By contrast, another agency offers accreditation for assisted living facilities or for an entire Life Plan Community (CCRC) operation, including some degree of financial oversight. That agency is CARF.

CARF. Another accreditation agency for nursing or long-term care facilities is CARF (Commission on Accreditation of Rehabilitation Facilities). www.carf.org CARF began on the rehabilitation side and expanded to cover other non-hospital settings. Unlike The Joint Commission, CARF also offers an accreditation program for the entirety of a Continuing Care Retirement Community (CCRC) or Life Plan Community, and not just the nursing center component. CARF also offers accreditation for assisted living providers.

Like The Joint Commission, CARF accreditation is comparatively rare. Accredited providers must pay fees to the accreditation agency for review. And there is staff expense, time and effort to qualify for accreditation. In some areas where competitors are accredited, there’s more incentive to pay the price. Accreditation helps a facility standout from the crowd.

Nursing homes that are accredited by The Joint Commission can be found on JCAHO’s search site. (https://www.qualitycheck.org)

Communities that are CARF accredited are listed on the CARF website. (http://www.carf.org)

3. Do Federal and State guidelines require licensed senior communities to be accredited?

Short answer. No. But some state agencies may accept accreditation in lieu of state inspections as “deemed” compliance with certification requirements.

4. Does Medicare’s 5-star rating impact accreditations? Does it impact the state license?

Medicare has it’s own tracking metrics, some of which are shared or similar to those used by accreditation agencies, but Medicare does not directly credit accreditation. Nor do accreditation agencies directly credit a provider’s Medicare Star Rating. Because of the overlap in focus, there is some correlation between higher Medicare Star ratings and accreditation, but accreditation doesn’t cause a better Medicare Star rating or vice versa. These are complementary measures. Check for both.

Medicare Star Ratings are available for every nursing facility (NF) certified to receive Medicare payments. (Private pay only facilities are not rated, but serve a comparatively narrow niche.)

Accreditation is still rare and accredited facilities are concentrated in denser, urban markets. Many consumers will have no accredited facilities from which to choose.

5. Does Accreditation Mean Quality?

Should consumers insist on accreditation for their nursing homes, long-term care facilities, or continuing care retirement communities (CCRCs)? Is accreditation a predictor of better quality? Yes.

You’d like to think that accreditation produces better quality. The Joint Commission would certainly expect that. A recent study by Scott C. Williams and other employees of The Joint Commission attempts to make the case. http://www.jamda.com/article/S1525-8610(16)30303-6/pdf

The study controlled for other potential causes of differences in quality including:

* Facility size

* Ownership type (e.g., for-profit vs. not-for-profit)

Comparing Public Quality Ratings for Accredited and Nonaccredited Nursing Homes

The nursing homes were evaluated on quality by their performance in Medicare’s Five-Star Quality Rating and its component parts (health inspection, quality measures, staffing, and Registered Nurse or RN staffing).

For more on the Medicare 5-Star Rating Systems see our summary at https://agingwithfreedom.com/how-to-read-medicare-star-ratings/

The Joint Commission can breathe a sigh of relief. Across the various component parts, accredited nursing homes did statistically better at the 95% confidence level (P < .05). But there was no statistically significant difference in the overall or combined 5-Star Rating. Digging into the details, the accredited nursing homes tended to have both fewer and less severe deficiencies. And had fewer payment denials. From the perspective of residents, both results are particularly valuable.

This is not to say that The Joint Commission accreditation program causes better quality results. There may be self-selection by higher quality nursing homes to seek accreditation. This may be reflected in the finding that accredited nursing homes are larger than their non-accredited peers.


From a consumer’s viewpoint, the lesson is, if you have the choice between a non-accredited facility and a facility accredited by The Joint Commission, go with the accredited facility if they are otherwise comparable in Medicare 5-Star ratings.

We can infer that CARF accreditation is similarly a mark of higher quality.

The bad news is that such accredited facilities are rare and located primarily in high-density urban markets.

So far consumers haven’t insisted upon accreditation. Neither accreditation agency makes a concerted effort to promote accreditation directly to consumers. (We think this is a mistake.)

Until consumers insist on higher standards, accreditation will continue to be rare. Smart consumers should factor accreditation status into their selection criteria, if available. Most consumers will not have any nearby accredited facilities. Start with Medicare’s 5-Star Rating system to evaluate the certified facilities near you.

It might be causation or self-selection, but accreditation does predict better management and better outcomes.