How Nursing Homes Get Medicare-Certified: Survey, Deficiency, CCN Issuance, and Ongoing Reporting
Before a nursing home can bill Medicare, it must earn a Certification and Compliance Number (CCN) from the Centers for Medicare & Medicaid Services. That number is issued only after a state survey agency confirms the facility meets the federal conditions of participation — a threshold that triggers ongoing inspection cycles, public deficiency reporting, and annual recertification. The process is more involved than a single inspection: it spans application, multi-day survey, citation adjudication, and continuous reporting obligations that continue for the life of the certification.
The process, step by step
Submit an application to the state survey agency
The nursing home operator submits a Medicaid/Medicare enrollment application (Form CMS-855A) and a provider agreement request to the state health department's survey and certification division. The application identifies the owner, administrator, location, and licensed bed count.
Source ↗State survey agency schedules an initial certification survey
Once the application is accepted, the state agency sends a survey team — typically 2–5 registered nurses and other clinicians — to the facility for an unannounced or scheduled multi-day visit. Surveyors assess compliance with all federal Conditions of Participation (42 CFR Part 483, Subpart B) covering resident rights, quality of care, staffing, infection control, and physical environment.
Source ↗Surveyors document deficiencies on Form CMS-2567
Any departure from the Conditions of Participation is recorded as a deficiency on the Statement of Deficiencies (Form CMS-2567). Each deficiency is assigned a scope-and-severity tag (A–L) indicating how widespread the problem is and whether it caused actual harm. Tags F-Tag numbers map to specific regulatory requirements.
Source ↗Facility submits a Plan of Correction
The facility has 10 calendar days to submit a written Plan of Correction (PoC) for each cited deficiency, specifying how it will correct the problem and by what date. CMS does not approve or disapprove PoCs, but they are public record and may be reviewed during future surveys.
Source ↗State agency recommends certification to CMS regional office
If the survey finds the facility substantially meets the Conditions of Participation — meaning no immediate jeopardy and no uncorrected harm-level deficiencies — the state survey agency recommends certification. The CMS regional office reviews the recommendation and, if approved, issues a certification.
Source ↗CMS issues a Certification and Compliance Number (CCN)
Upon certification, CMS assigns a unique 6-digit CCN (formerly called a Medicare Provider Number) to the facility. The CCN is the identity anchor used in all CMS data systems: Care Compare, cost reports, staffing data, and ownership disclosure. It appears in the CMS Provider of Services file and is permanent for the life of the certification.
Source ↗Facility begins ongoing reporting under CASPER and PBJ
Certified facilities must transmit staffing data electronically to the Payroll-Based Journal (PBJ) system quarterly. They must also submit annual cost reports (CMS-2540) and maintain compliance with the Minimum Data Set (MDS) resident assessment reporting. Failure to submit required data triggers enforcement action.
Source ↗Annual recertification survey
After initial certification, the facility must undergo a standard annual recertification survey, typically every 9–15 months (the federal target is 12 months). Surveys are unannounced. Each survey either confirms continuing certification or results in deficiency citations, remediation requirements, or — for the most serious failures — termination of the provider agreement.
Source ↗
Eligibility and application
Any skilled nursing facility (SNF) or nursing facility (NF) seeking Medicare reimbursement must first be licensed by the state and meet basic physical-plant requirements. The operator completes Form CMS-855A, the Medicare enrollment application for institutional providers, identifying the authorized official, all owners with 5% or greater interest, the administrator of record, and the licensed bed count. An NPPES National Provider Identifier (NPI) must already be active for the facility before enrollment can proceed.
The application is filed with the state survey and certification agency, which acts as CMS's agent for all long-term care surveys. States receive CMS funding under the State Performance Standards System to conduct surveys; the federal standards are set at 42 CFR Part 488.
Facilities applying for both Medicare and Medicaid certification — a dual-certification that covers the vast majority of nursing homes — submit a combined application. CMS data from the Provider of Services (POS) file shows approximately 99% of participating facilities hold dual certification.
The initial certification survey
The initial certification survey is the most comprehensive inspection a nursing home faces. Unlike annual recertification surveys, which use the Quality Indicator Survey (QIS) sampling methodology, the initial survey is a full-facility assessment. Surveyors spend typically 3–5 days on-site reviewing medical records, observing care delivery, interviewing residents and staff, and inspecting the physical environment.
Federal surveyors use the CMS Survey Protocol for Long-Term Care Facilities (Appendix PP of the State Operations Manual) as their guide. The survey covers over 180 distinct F-Tags organized under the seven major categories of the Conditions of Participation: resident rights and facility responsibilities, freedom from abuse and neglect, resident assessment, quality of care, quality of life, nursing services, and administration.
For an initial certification, the standard is whether the facility is in 'substantial compliance' — meaning no deficiencies at scope-and-severity level G or above (actual harm to one or more residents) and no immediate jeopardy. Facilities with only minor or moderate deficiencies at levels A–F may still receive certification while working on corrective plans.
Deficiencies and the citation process
Each regulatory requirement under 42 CFR Part 483 is assigned an F-Tag. When surveyors find a departure from that requirement, they record it on Form CMS-2567 — the Statement of Deficiencies and Plan of Correction. The CMS-2567 is a public document; it is uploaded to CMS Care Compare within 14 days of survey completion.
Deficiencies are rated on a scope-and-severity grid. Scope runs from isolated (one resident or occurrence), to pattern (multiple residents or recurrence), to widespread. Severity runs from potential for harm only (levels A–C), through actual harm (D–F for no immediate jeopardy; G–I for actual harm without immediate jeopardy), to immediate jeopardy (J–L). The severity level directly determines which enforcement remedies CMS can impose.
Fonteum's nursing home deficiency study covers 418,148 citations across 14,635 facilities — drawn from CMS Care Compare and the CMS Health Deficiencies dataset. The national average is 5.59% G-or-higher (actual harm) deficiency rate, with substantial state-level variation.
CCN issuance: the facility's permanent identifier
The Certification and Compliance Number is a 6-character alphanumeric identifier assigned at initial certification. For skilled nursing facilities, CCNs follow a state-specific prefix pattern (e.g., California facilities begin with '05', Texas with '67'). The number never changes as long as the facility holds its provider agreement — it persists through ownership changes, name changes, and renovations.
Because the CCN is stable, it serves as the join key across every CMS dataset: Care Compare quality ratings, the PBJ staffing database, HCRIS cost reports, the PECOS ownership records, and the OIG LEIE exclusion list. Fonteum's CMS Provider of Services (POS) file table — 68,211 rows as of the most recent snapshot — functions as the CCN identity backbone.
When a facility closes, its CCN is retired and never reused. Ownership changes are separately disclosed through the PECOS Ordering and Referring (O&R) file and the SNF All Owners file, but the CCN itself remains constant.
Ongoing reporting obligations
Certification is not a one-time event. Facilities must submit payroll and staffing data to the CMS Payroll-Based Journal (PBJ) system every quarter, covering each employee type, hours worked per day, and census data. PBJ replaced the old staffing 'self-reported' model in 2017 and is now the source of the staffing component in the CMS 5-star rating system.
Annual cost reports (Form CMS-2540) must be filed within 5 months of fiscal year end. The cost report captures total revenue, Medicare/Medicaid days, wage and benefit costs, and capital expenditures — it is the primary data source for Fonteum's HCRIS integration and for the nursing home chain ownership and financial health analyses.
Facilities participating in Medicare must also conduct Minimum Data Set (MDS) assessments on every resident at admission, quarterly, annually, and at significant changes in condition. MDS data flows into the quality measures component of the 5-star rating and is used in the CMS quality reporting program.
Recertification surveys and enforcement
Annual recertification surveys must occur no longer than 15 months after the previous standard survey, with a 12-month target average. States that fall behind their survey timelines face CMS funding reductions. Surveys are unannounced by federal law — the inspector general has found that announced surveys produce better-than-average deficiency findings that do not reflect typical operations.
When deficiencies are found at or above level G (actual harm), CMS can impose a range of remedies: civil money penalties of $108–$21,393 per day or per instance, denial of payment for new Medicare admissions, directed in-service training, a state monitor, temporary management, and termination of the provider agreement. As of Fonteum's most recent enforcement study, $467 million in civil money penalties have been issued against 2,553 facilities over a 3-year dataset.
Facilities on the Special Focus Facility (SFF) program — a CMS watch list for the poorest performers — receive surveys twice per year and face more aggressive enforcement timelines. SFF status is based on a weighted sum of deficiency scope-and-severity over 36 months.
Frequently asked questions
- How long does Medicare certification take?
- The timeline varies by state and workload, but the process from application submission to CCN issuance typically takes 3–6 months. The bulk of that time is scheduling and conducting the initial certification survey. States experiencing surveyor shortages have reported backlogs that push timelines to 9–12 months.
- Can a nursing home operate without a CCN?
- A nursing home can operate as a state-licensed facility and bill only Medicaid if it holds a state Medicaid certification without a Medicare CCN. However, the vast majority of facilities hold both Medicare and Medicaid certification. Without a Medicare CCN, the facility cannot receive Part A skilled nursing facility payments.
- What happens when a nursing home loses its Medicare certification?
- CMS can terminate a provider agreement — the contractual relationship underlying Medicare certification — if a facility fails to correct serious deficiencies, is placed on the Special Focus Facility program and does not improve, or poses immediate jeopardy. Termination requires the facility to discharge Medicare and Medicaid residents to other facilities. The CCN is retired upon termination.
- Is the survey process the same in every state?
- The federal Conditions of Participation are uniform across all states. The survey methodology — CMS's Quality Indicator Survey (QIS) and the associated State Operations Manual guidance — is also federally standardized. However, states have some discretion in how they staff and schedule surveys, which leads to variation in survey frequency and deficiency rates across states.
- Where can I see a nursing home's deficiency history?
- CMS Care Compare (care.medicare.gov/nursing-homes) publishes the last three years of standard survey deficiencies, complaint surveys, and enforcement actions for every certified nursing home. Fonteum's nursing home research pages provide structured access to the same underlying data with field-level source provenance.
Reviewed by Jennifer Montecillo, MD, medical reviewer. Non-practicing medical reviewer. Last reviewed: June 2026. Data last updated: 2026-06-03.
This explainer draws from federal primary sources. Every figure is traceable to a specific CMS dataset with provenance documentation. Data sources → Corrections log → Methodology library →
Federal data is in the public domain under U.S. Government Works. Fonteum analysis and synthesis are copyright Fonteum, Inc.