The Board of Commissioners approved a revision to POLICY #4 TYPES OF COMMISSION ACTIONS ON APPLICATIONS FOR ACCREDITATION. Pursuant to Commission Policy #11, proposed policy changes are submitted to accredited programs for review and comment prior to implementation.

Please provide any comments by email to Yovanka Heyburn at yheyburn@acenursing.org no later than April 16, 2014. The Commissioners will consider these comments prior to implementation of the policy.

Thank you for reviewing this policy change. We appreciate your interest and support of the accreditation process.

POLICY #4 TYPES OF COMMISSION ACTIONS ON APPLICATIONS FOR ACCREDITATION

A nursing program is considered for initial or continuing accreditation by the ACEN Commissioners when it demonstrates compliance with the Standards of accreditation.

INITIAL ACCREDITATION

Granted

Initial accreditation* of a nursing program is granted when the program demonstrates compliance with all ACEN Accreditation Standards. Next review is in five (5) years.

*Accreditation is effective as of the accreditation cycle in which the visit took place.

Denied

Initial accreditation of a nursing program is denied when a program does not demonstrate compliance with all ACEN Accreditation Standards. The program may re-initiate the accreditation process at any time.

CONTINUING ACCREDITATION

Granted

  • Continuing accreditation of a nursing program is granted when the program is in compliance with all Accreditation Standards. Next review in eight (8) years.
  • Continuing accreditation with conditions is granted when the program is found to be in non-compliance with one (1) or two (2) Accreditation Standards. Next review in two (2) years for clinical doctorate, master’s, baccalaureate, associate, and diploma programs, and 18 months for practical nursing programs.
  • Continuing accreditation of a nursing program with warning is granted when the program is found to be in non-compliance with three (3) or more of the Accreditation Standards. Next review (full site visit with Self-Study Report) in two (2) years for clinical doctorate, master’s, baccalaureate, associate, and diploma programs, and 18 months for practical nursing programs.
  • Continuing accreditation of a nursing program with removal of condition status is granted when the program is found to be in compliance with all Accreditation Standards. Next review in six (6) years for clinical doctorate, master’s, baccalaureate, associate, and diploma programs, and six and one half (6½ ) years for practical nursing programs.
  • Continuing accreditation of a nursing program with a removal of warning status is granted when the program is found to be in compliance with all Accreditation Standards. Next review in eight (8) years.

Denied

  • Continuing accreditation is denied when a program with conditions or warning status is reviewed and found to be in continued non-compliance with any Accreditation Standard. The program is removed from the listings of accredited programs. It may reinitiate the application process for initial accreditation at any time.

ACCREDITATION WITH CONDITIONS OR WARNING STATUS

  • The Commission places conditions on a program’s continuing accreditation when the program has been found to be in non-compliance with one (1) or two (2) Accreditation Standards.
    • The conditions include the Commission request for a Follow-Up Report or a Follow-Up Report with a Follow-Up Visit within the specified period of time addressing the Standard(s) with which the program has been found to be in non-compliance. The Follow-Up Report, or Follow-Up Report and Follow-Up Visit Report, and Evaluation review Panel (ERP) Summary will constitute the basis for Commission action. The action is either to accept the report, finding the program in compliance with all ACEN Standards, or not accept the report as the program remains in non-compliance. Programs in compliance will be granted continuing accreditation. Next review in six (6) years for clinical doctorate, master’s, baccalaureate, associate, and diploma programs, and six and one half (6½) years for practical nursing programs. Programs not in compliance with ACEN Standards will be denied continuing accreditation.
  • The Commission places an accredited program on warning status when the program has been found to be in non-compliance with three (3) or more Accreditation Standards.
    • When a program has been placed on warning status, the Commission must request a new Self-Study Report with a revisit within the specified period of time. The new Self-Study, Site Visitors’ Report, and ERP Summary will constitute the basis for the Commission action to remove the warning status and grant continuing accreditation for eight (8) years, or to deny continuing accreditation and remove the program from the listings of accredited programs.
  • The maximum period for accreditation with conditions or warning status for master’s, baccalaureate, associate, and diploma programs is two (2) years from the Commission action. If full compliance with the Accreditation Standard(s) is not demonstrated within two (2) years, continuing accreditation will be denied.
  • The maximum period for accreditation with conditions or warning status for practical nursing programs is 18 months from the Commission action. If full compliance with the accreditation standard(s) is not demonstrated within 18 months, continuing accreditation will be denied.

If a nursing program has not remedied deficiencies at the conclusion of its maximum monitoring period, the Commission must (1) remove the nursing program from the list of accredited programs, or (2) continue accreditation for Good Cause.  If accreditation is extended for Good Cause, the nursing program must also be placed on continued accreditation with warning.

A nursing program’s accreditation can be extended for Good Cause if:

  1. The nursing program has demonstrated significant recent accomplishments in addressing non-compliance; and
  2. The nursing program has documented that it has the potential to remedy all deficiencies within the extended period as defined by the Commission; that is, that the nursing program provides evidence which makes it reasonable for the Commission to determine it will remedy all deficiencies within the extended time defined by the Commission; and
  3. The nursing program provides assurance to the Commission that it is not aware of any other reasons, other than those identified by the Commission, why the nursing program could not be continued for Good Cause.