ACEN Accreditation Manual – Policy 12

ACCREDITATION MANUAL  •  SECTION I GENERAL INFORMATION  •  SECTION II POLICIES  •  SECTION III STANDARDS AND CRITERIA  •  GLOSSARY

ACEN Accreditation Manual – Section II Policies

POLICY #12 Nursing Program Records on File

The Accreditation Commission for Education in Nursing (ACEN) will retain and destroy governing organization/nursing program accreditation records, non-accreditation records, and official correspondence as required by law, applicable regulations, and ACEN policies.

This policy does not seek to provide obligations that may conflict with federal law or regulations, State Sunshine laws, Open Records, or other record retention laws, and shall be construed wherever possible consistent with such laws; should an apparent conflict arise between this policy and federal or state law, in all instances such law shall prevail.

Accreditation Records

Accreditation records mean those documents (paper or digital) created by the governing organization/nursing program or created by the ACEN and are in the possession of the ACEN that relate to the review of a governing organization’s/nursing program’s seeking initial accreditation, continuing accreditation, or approval of a substantive change.

  1. Initial or continuing accreditation records shall be retained for one accreditation cycle; five years for initial accreditation or eight years for continuing accreditation and then destroyed. In the case of appeal or arbitration, required records shall be retained until the conclusion of the respective process, then destroyed in five years for initial accreditation or eight years for continuing accreditation, whichever is later. These records include the following:
    1. Nursing program’s written report (i.e., Self-Study Report, Follow-Up Report, or Focused Visit Report) excluding supporting evidence.
    2. Site visit team report, if applicable (i.e., Site Visit Report, Follow-Up Site Visit Report, Focused Site Visit Report).
    3. Nurse Administrator Response Form, if applicable.
    4. Evaluation Review Panel Summary.
  1. Substantive change records shall be retained for three years and then destroyed. These records include the following:
    1. Written documents (paper or digital) created by the governing organization/nursing program as required at the time of submission for Procedure 1, 2, 3, or 4 in accordance with Policy #14 Reporting Substantive Changes.
  1. Candidacy records shall be retained for three years or until initial accreditation is earned, whichever occurs first, then destroyed. These records include the following:
    1. Written documents (paper or digital) created by the ACEN or created by the governing organization/nursing program as required at the time of submission in accordance with Policy #34 Candidacy for a Governing Organization/Nursing Program Seeking Initial Accreditation and candidacy process.
  1. Annual Report records shall be retained for eight years. These records include the following:
    1. Written documents (paper or digital) created by the governing organization/nursing program as required at the time of submission for the ACEN Annual Report.

Non-accreditation Records

Complaint records shall be retained for eight years. These records include the following:

  1. Written documents (paper or digital) created by the complainant or created by the governing organization/nursing program at the time of submission as required in accordance with Policy #20 Complaints Against an Accredited Program.

Official Correspondence Records

Official correspondence includes correspondence on ACEN letterhead signed by the ACEN Chief Executive Officer or designee and addressed to the governing organization’s chief executive officer and/or nurse administrator.

  1. Initial or continuing accreditation official correspondence shall be retained permanently. These include the following:
    1. Accreditation decision letter to the governing organization’s chief executive officer and nursing program’s nurse administrator
    2. Letter of voluntary withdrawal from initial or continuing accreditation process if the governing organization/nursing program withdraws before Board of Commissioners’ decision; see Policy #7 Voluntary Withdrawal from ACEN Accreditation. In this case, only the governing organization’s/nursing program’s withdrawal letter and ACEN acknowledgement letter are retained permanently, and all other documents (paper or digital) created by the governing organization/nursing program or created by the ACEN are destroyed.
    3. Letter of voluntary withdrawal from candidacy process. In this case, only the governing organization’s/nursing program’s withdrawal letter and ACEN acknowledgement letter are retained permanently, and all other documents (paper or digital) created by the governing organization/nursing program or created by the ACEN are destroyed.
  1. Substantive change official correspondence shall be retained permanently. This includes the following:
    1. Board of Commissioners’ or Chief Executive Officer’s decision letter.
  1. Other official correspondence shall be retained permanently as determined by the Chief Executive Officer or designee.
    1. Correspondence deemed critical to the accreditation functions of the ACEN.

Applicability

  1. This policy applies to paper or digital accreditation records, non- accreditation records, and official correspondence wherever and however they are retained.
  2. Accreditation records, non-accreditation records, and official correspondence do not include any other type of records (e.g., administrative, business, corporate) created by the governing organization/nursing program or created by the ACEN and are in the possession of the ACEN.

Policy #12 History
Revised November 2015
Revised July 2020
Edited June 2023

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