POLICY #14
REPORTING SUBSTANTIVE CHANGES

SUBSTANTIVE CHANGE POLICY AND PROCEDURE

1. ACEN policies and the Standards and Criteria apply to all ACEN-accredited nursing programs wherever the nursing program is located or however the nursing program is delivered. Failure to comply with the Standards and Criteria or with the procedures referred to in this policy could result in the imposition of a stipulation (e.g., conditions, warning, good cause) or the nursing program being removed from the list of ACEN-accredited nursing programs.
2. Policy #14 Reporting Substantive Changes is partially based on federal regulations and reflects best practices to ensure that a nursing education program remains in compliance with the ACEN Standards and Criteria and that academic quality is maintained.
3. The ACEN substantive change policy applies only to accredited nursing programs. Programs that have achieved candidacy status should refer to Policy #34 for information about substantive changes that must be reported to the ACEN prior to initial accreditation. All substantive change submissions are reviewed using one of the four identified procedures:
   
   a. Procedure 1: Review of a substantive change requiring the approval of the Board of Commissioners or Chief Executive Officer or designee prior to implementation. ACEN staff will conduct a preliminary review of all Procedure 1 changes to verify that review and a decision by the ACEN Board of Commissioners or ACEN Chief Executive Officer or designee is required. The Chief Executive Officer or designee may approve or deny the Procedure 1 substantive changes as delegated by the Board of Commissioners to the Chief Executive Officer or designee in accordance with 34 CFR 602.22(a)(2)(i). Verified Procedure 1 substantive changes not delegated by the Board of Commissioners to the Chief Executive Officer or designee in accordance with 34 CFR 602.22(a)(2)(i) are referred to the Board of Commissioners for approval or denial. Additionally, the following are referred to the Board of Commissioners for approval or denial:
   
   i. Any proposed substantive change submitted by a nursing program currently on continuing accreditation with warning or continuing accreditation for good cause.
   
   ii. A proposed substantive change submitted by an institution placed on advanced payment method, reimbursement payment method, or heighted cash management payment method in accordance with 34 CFR 668.162 by the U.S. Department of Education for Title IV federal funding when the ACEN is the institutional accrediting agency/Title IV gatekeeper.
   
   b. Procedure 2: Review of a substantive change in accordance with 34 CFR 602.22(a)(1)(ii)(c); notification prior to implementation is required.
   
   c. Procedure 3: Review of the closing of a governing organization and/or nursing program. Review of the closing of the closing of an off-campus instructional site or branch campus where a nursing program is offered.
   
   d. Procedure 4: Review of events as determined by the ACEN.
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4. ACEN staff review all substantive change submissions. All procedure 2, 3, and 4 substantive changes may be approved or denied by the Chief Executive Officer or designee or referred to the Board of Commissioners for further action.
5. Denial of a substantive change is not appealable. A nursing program that fails to gain approval of a substantive change may resubmit a revised or updated submission following the guidelines and timeframes described in this policy.
6. A governing organization/nursing program in an appeals process, an arbitration process, or a litigation process with the ACEN is not eligible for consideration of any substantive change.
7. Nursing programs with a status of continuing accreditation with warning or continuing accreditation for good cause may not implement a substantive change until the continuing accreditation with warning or continuing accreditation for good cause status has been resolved.
   
   a. Exceptions may be made for substantive changes deemed necessary to ensure the nursing program’s compliance with the Standards and Criteria with which the program was found to be in non-compliance. For example, a nursing program may implement a curriculum change to address non-compliance with Standard 4 Curriculum. However, a nursing program may not increase student enrollment, add new nursing program options, add new teaching locations, implement distance education, or a nursing education unit cannot add new nursing program types until the continuing accreditation with warning or the continuing accreditation for good cause status has been resolved.
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8. A nursing program may withdraw or discontinue a substantive change at any time prior to the decision by the Board of Commissioners or the Chief Executive Officer or designee by submitting a formal letter to the Chief Executive Officer or designee withdrawing the substantive change.
9. Once a nursing program submits a substantive change, and the document is reviewed by either the ACEN staff or the decision by the Board of Commissioners or the Chief Executive Officer or designee is made; any information included therein indicating possible non-compliance with any of the ACEN Standards and Criteria may lead the ACEN to further review the nursing program, even if the submission is withdrawn or if approval of the substantive change is denied.
10. The substantive change decision (from the Board of Commissioners or Chief Executive Officer) is effective as of the date of the board’s or Chief Executive Officer’s decision; this date will be noted in the decision letter sent to the governing organization/nursing program.
    
    a. The effective date may not pre-date either an earlier denial of the substantive change or the current review and subsequent approval/denial of the substantive change.
    
    b. Approval or denial of a substantive change is based on a review of written documentation submitted by the nursing program and the understanding and application of the current ACEN policies and the Standards and Criteria. The approval of a substantive change at the time of submission does not guarantee that after a future review of the program by peer evaluators (e.g., focused visit or continuing accreditation visit), the Board of Commissioners will determine that the program is in compliance with all related Standards and Criteria affected by the substantive change.
    
    c. The effective date of a change of ownership is the date the Board of Commissioners approves the change of ownership; the effective date of a change of ownership may not be more than 30 calendar days prior to the change of ownership.
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11. Extensive substantive changes by a nursing program may accelerate the date for the nursing program’s next comprehensive continuing accreditation visit. Examples of triggers for an accelerated reaccreditation include the following changes: proliferation of branch campuses or off-campus instructional sites where the nursing program is offered, frequent change of ownership, merger or consolidation with other nursing programs, significant increase in enrollment in the nursing program, or rapid proliferation of new nursing program options.
12. This policy may not address all substantive changes made by the program. Programs implementing significant modifications or expansions to the nature and scope of the ACEN-accredited nursing program should contact the ACEN to discuss the program’s plans. The ACEN reserves the right to classify significant changes other than those described below as substantive in nature and to follow up accordingly. The follow-up procedure may include a focused visit.
13. If the ACEN is the institutional accrediting agency/Title IV gatekeeper for the governing organization/nursing program, and the governing organization/nursing program fails to follow the ACEN substantive change policy and procedures; the nursing program may lose its Title IV funding or be required (as determined by the U.S. Department of Education) to reimburse money received related to the unreported substantive change. In addition, the nursing program may be referred to the Board of Commissioners for the imposition of a stipulation (e.g., conditions, warning, good cause) or removal from the list of ACEN-accredited nursing programs.
14. It is the responsibility of each nursing program to notify the ACEN of major changes in a nursing program to ensure maintenance of accreditation status and protection of students in accordance with Policy #14 Reporting Substantive Changes and when required to seek approval prior to the initiation of the substantive change. Failure to report a substantive change places the accreditation status of a nursing program in jeopardy and may have consequences related to Title IV eligibility, as determined by the U.S. Department of Education. If a nurse administrator is unclear as to whether a change is substantive in nature, she/he should contact the ACEN staff for consultation.
15. The ACEN Board of Commissioners reserves the right to reconsider the accreditation status of a nursing program at any time. The Board of Commissioners may also take action to require monitoring of a nursing program due to non-compliance with any Accreditation Standard.
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REPORTING THE VARIOUS TYPES OF SUBSTANTIVE CHANGE

The following tables provide an overview of the different types of substantive change, the specific procedure to be used for each, the respective approval and/or notification requirement, the reporting timeline, and submission procedures. Please read the full text of the listed substantive change from the appropriate table:

1. Table 1: When ACEN is not the institutional accreditor/Title IV gatekeeper for the governing organization/nursing program.
2. Table 2: When ACEN is the institutional accreditor/Title IV gatekeeper for the governing organization/nursing program.

NOTE: For definitions of bolded terms in the tables below, visit the ACEN Accreditation Glossary Page.

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TYPES OF COMMISSION ACTIONS

For verified Procedure 1 substantive changes that are approved by the Board of Commissioners or Chief Executive Officer as delegated by the Board of Commissioners (or when the ACEN staff refer a substantive change for additional consideration), the Board of Commissioners or Chief Executive Officer may take the following actions.
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BOARD OF COMMISSIONERS ACTIONS

1. Approve the substantive change; no focused visit required.
2. Approve the substantive change and authorize a focused visit for review of compliance with specified Standards and Criteria, and the Focused Site Visit Report will be reviewed by the Board of Commissioners in accordance with Policy #19 Focused Site Visit.
   
   a. If the ACEN is the governing organization’s institutional accrediting agency/Title IV gatekeeper, and the nursing program is adding its first or second branch campus or new off-campus location where more than 50% of the of the nursing program is offered or when there is a change in legal status, form of control, or ownership; the focused visit must occur within six calendar months after the implementation of the substantive change.
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3. Approve the substantive change and require a written report about the status of the implementation of the substantive change within a specified timeframe.
4. Request additional information regarding areas of concern with specified criteria; the due date for the additional information may not exceed one calendar year from the date of the request, and one of the following:
   
   a. Accept the additional information and approve the substantive change; no further information is required.
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   b. Accept the additional information and approve the substantive change; authorize a focused visit for review of compliance with specified Standards and Criteria; the focused visit must occur within six calendar months. The Focused Site Visit Report will be reviewed by the Board of Commissioners in accordance with .
   
   c. Deny the substantive change. This is not an appealable action.
   
   d. Deny the substantive change and authorize a focused visit for review of compliance with specified Standards and Criteria. This is not an appealable action. The Focused Site Visit Report will be reviewed by the Board of Commissioners in accordance with .
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CHIEF EXECUTIVE OFFICER OR DESIGNEE ACTIONS

For substantive changes categorized as Procedures 2, 3, and 4, the ACEN Chief Executive Officer or designee may take the following actions:

1. Approve or deny the substantive change; no further information is required.
2. Request additional information; the due date for the additional information may not exceed one calendar year from the date of the request; and upon receipt may perform one of the following:
   
   a. Accept the additional information and approve or deny the substantive change after review of the additional information.
   
   b. Refer the substantive change submission and additional information to the Board of Commissioners for consideration and possible further action.
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3. Refer the substantive change request to the Board of Commissioners for consideration and possible further action.

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