ACEN Accreditation Manual – Policy 14


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

ACEN Accreditation Manual – Section II Policies

POLICY #14
Reporting Substantive Changes


GLOSSARY OF TERMS
Please see the ACEN Glossary for the definition of the following terms:

POLICY STATEMENTS REGARDING SUBSTANTIVE CHANGE

  1. 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 (i.e., conditions, warning, good cause) or the nursing program being removed from the list of accredited nursing programs.
  2. ACEN staff will conduct a preliminary review of all Procedure 1 changes to verify that approval or denial by the ACEN Board of Commissioners or ACEN Chief Executive Officer is required. The Chief Executive Officer may approve or deny the Procedure 1 substantive changes as delegated by the Board of Commissioners to the Chief Executive Officer per 34 CFR 602.22(a)(2)(i).
    Verified Procedure 1 substantive changes not delegated by the Board of Commissioners to the Chief Executive Officer per 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:

    1. Any proposed substantive change submitted by a nursing program currently on continuing accreditation with warning or continuing accreditation for good cause.
    2. A proposed substantive change submitted by an institution placed on advanced payment method, reimbursement payment method, or heighted cash management payment method per 34 CFR 668.162 by the U.S. Department of Education for Title IV federal funding when the ACEN is the Title IV gatekeeper for the nursing program.
  3. ACEN staff review all Procedure 2, 3, and 4 substantive changes. These substantive changes may be accepted or not accepted by the Chief Executive Officer or referred to the Board of Commissioners for further action.
  4. Denial or non-acceptance of a substantive change is not appealable. A nursing education unit that fails to gain approval of a substantive change may resubmit a revised prospectus or letter of notification following the guidelines and timeframes described in this document.
  5. A governing organization/nursing program in the appeals process or in arbitration with the ACEN is not eligible for consideration of any substantive change.
  6. Nursing programs that were granted continuing accreditation with warning or continuing accreditation for good cause by the Board of Commissioners as a result of the last accreditation review may not implement a substantive change until the continuing accreditation with warning or continuing accreditation for good cause status has been resolved. 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 add new nursing program types until the continuing accreditation with warning or continuing accreditation for good cause status has been resolved.
  7. 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 program changes that should be reported to the ACEN prior to initial accreditation.
  8. Procedures 1, 2, 3, and 4 may not address all substantive changes that ACEN will review in the interim between a nursing program’s reaccreditation cycles. Therefore, 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.
  9. A nursing program may withdraw/discontinue a substantive change at any time prior to the decision by the Board of Commissioners or the Chief Executive Officer by submitting a formal letter to the Chief Executive Officer withdrawing the substantive change.
  10. 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, any information included therein that indicates possible non-compliance with any of the Standards and Criteria may lead ACEN to further review the nursing program, even if the prospectus is withdrawn or approval of the substantive change is denied.
  11. Submission and acceptance of a substantive change for the addition of a new degree level does not constitute approval of a new degree level at an ACEN-accredited program. In order for a program to be ACEN accredited, the program must achieve Candidacy and be granted initial accreditation by the Board of Commissioners. Information about the Candidacy and initial accreditation process is available at: https://www.acenursing.org/candidacy.
  12. The Board of Commissioners’ or Chief Executive Officer approval or denial of a substantive change is effective as of the date of the Board’s/CEO’s approval or denial; this date will be noted in the approval or denial letter sent to the governing organization/nursing program. The Chief Executive Officer’s acceptance or non-acceptance of a substantive change is effective as of the date of the acceptance or non-acceptance letter sent to the governing organization/nursing program.
    1. The effective date may not pre-date either an earlier denial of the substantive change or the current review and subsequent approval/denial or acceptance/non-acceptance of the substantive change.
    2. Acceptance, non-acceptance, approval, or disapproval 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 current Standards and Criteria. The acceptance or approval of a substantive change at the time of submission does not guarantee that, after a review of the program by peer evaluators in the future (i.e., 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.
    3. 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.
  13. Extensive substantive changes by a nursing education unit 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.
  14. If the ACEN is the Title IV gatekeeper for the nursing program and the nursing program fails to follow the ACEN substantive change policy and procedures, the nursing program may lose its Title IV funding or be required by the U.S. Department of Education to reimburse it for money received for nursing programs 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 or warning) or removal from the list of accredited nursing programs.

NURSING PROGRAM RESPONSIBILITIES AND OBLIGATIONS
A substantive change is a significant modification or expansion of the nature and scope of a nursing program and/or nursing education.
It is the responsibility of each nursing education unit 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, 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 certification and eligibility. If a nurse administrator is unclear as to whether a change is substantive in nature, she/he should contact ACEN staff for consultation.
The ACEN 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.
REPORTING THE VARIOUS TYPES OF SUBSTANTIVE CHANGE
The different types of substantive change, the specific procedure to be used for each, the respective approval/notification requirement, and the reporting timeline are included in the following table. Submission procedures are explained in more detail following the table. Please read the full text under the appropriate procedure for details regarding reporting. Based on federal regulations and ACEN policy, a substantive change includes:

Type of Substantive Change

Prior Approval from ACEN Required

Review Procedure1

Focused Visit

Timeframe for Submission to the ACEN

CURRICULUM

Changing the way a governing organization or nursing program measures academic progress toward program completion, in clock hours, credit hours, semesters, trimesters, or quarters; or uses time-based or non-time-based methods2

Yes

Procedure 1

Possible

Four months prior to implementation of the change

Adding undergraduate or graduate nursing programs of study at a degree or credential level different from that which is included in the nursing education unit’s current accreditation

Yes

Procedure 2

No

Prior to implementation
See candidacy process for adding a new undergraduate or graduate nursing program at the new degree or credential level different from that which is currently included in the nursing education unit’s current accreditation

An increase, decrease, or substitution of 25% to 49% of the nursing credit/quarter/clock hours that represents a significant departure in the nursing content from the currently accepted/approved nursing courses required for completion of a nursing program

No

Procedure 25

Possible

Four months prior to implementation of the change

An increase, decrease, or substitution of 50% or greater of the nursing credit/quarter/clock hours that represents a significant departure in the nursing content from the currently accepted/approved nursing courses required for completion of a nursing program2

Yes

Procedure 1

Possible

Four months prior to implementation

Curriculum revisions involving an increase or decrease of 20% or greater of the total credit/quarter/clock hours for the nursing program of study from the currently accredited program of study2

Yes

Procedure 1

Possible

Four months prior to implementation of the change

PROGRAM OUTCOMES

The program’s overall (aggregated for the program as a whole) annual licensure examination/certification pass rates not meeting the benchmark established in Criterion 6.2

No

Procedure 4

Possible

Within 60 calendar days of the program knowing pass rate does not meet benchmark

The program’s overall (aggregated for the program as a whole) annual program completion rate over two consecutive academic years falling 25% or more below the program’s established expected level of achievement (ELA); or the annual program completion rate in a single year falling more than 40% below the program’s established ELA

No

Procedure 4

Possible

Within 60 calendar days of the program knowing completion rate does not meet benchmark

The program’s overall (aggregated for the program as a whole) annual job placement rate over two consecutive academic years falling 30% or more below the program’s established expected level of achievement (ELA); or the annual job placement rate in a single year falling more than 45% below the program’s established ELA

No

Procedure 4

Possible

Within 60 calendar days of the program knowing graduation rate does not meet benchmark

DISTANCE EDUCATION

Offering 50% to 100% of the number of nursing credit/quarter/clock hours via distance education2. Once approved to offer any nursing program via distance education, approval is not required to offer subsequent nursing program(s) via distance education.

Yes

Procedure 1

Possible

Four months prior to implementation of the change

Offering 25% to 49% of the number of nursing credit/quarter/clock hours via distance education

No

Procedure 25

No

Prior to implementation

Offering 1% to 24% of the number nursing credit/quarter/clock hours via distance education

N/A

N/A

No

N/A

PROGRAMS/PROGRAM OPTIONS

Adding undergraduate or graduate nursing programs of study at a degree or credential level different from that which is included in the nursing education unit’s current accreditation

Yes

Procedure 2

No

Prior to implementation
See candidacy process

Adding a nursing program option within a nursing program by deleting and/or substituting 50% or more of the existing nursing courses to form the new nursing program option2

Yes

Procedure 1

Possible

Four months prior to implementation of the change

Adding a nursing program option within a nursing program by deleting and/or substituting 1-49% of the existing nursing courses to form the new nursing program option

No

Procedure 25

Possible

Prior to implementation

Inactivating a nursing program

No

Procedure 2

No

Four months prior to implementation of the change

Reactivating a nursing program

No

Procedure 2

No

Four months prior to implementation of the change

Closing a nursing program

Yes

Procedure 3

Possible

Four months prior to implementation of the change

Acquiring another governing organization

Yes

Procedure 1

Possible

Four months prior to implementation of the change

Acquiring from another governing organization an accredited or non-accredited nursing program

Yes

Procedure 1

Possible

Four months prior to implementation of the change

Acquiring from another governing organization an off-campus instructional site where an accredited or non-accredited nursing program is offered

Yes

Procedure 1

Possible

Four months prior to implementation of the change

CHANGE IN STATUS: NURSING REGULATORY AGENCY/ACCREDITING AGENCY/TITLE IV

A change in approval status with the state regulatory agency for nursing; see ACEN Policy #17

N/A

Procedure 4

Possible

Within 60 calendar days of the program receiving notification

A negative or adverse action by the institutional accrediting agency; see ACEN Policy #18

N/A

Procedure 4

Possible

Within 60 calendar days of the program receiving notification

A change in Title IV status
(Applies only if ACEN is the Title IV gatekeeper for the nursing program)

N/A

Procedure 4

Possible

Within 60 calendar days of the program receiving notification

INSTRUCTIONAL SITES/BRANCH CAMPUSES/RELOCATIONS

Establishing a branch campus at which an ACEN-accredited nursing program is offered. Once approved to offer any nursing program at a branch campus within the nursing education unit (NEU) per ACEN records, approval is not required to offer any subsequent nursing program(s) within the NEU at the branch campus.4

ACEN is Title IV gatekeeper – Yes

Procedure 1

Required

Four months prior to implementation of the change

ACEN is not Title IV gatekeeper – Yes

Procedure 2

Possible4
Note: All new branch campuses must be reported whether or not a focused visit is required

Four months prior to implementation of the change

Establishing a new off-campus instructional site at which students can obtain 50% or more of the number of nursing credit/quarter/ clock hours required for completion of an ACEN-accredited nursing program. Once approved to offer any nursing program at an off-campus instructional site within the nursing education unit (NEU) per ACEN records, approval is not required to offer any subsequent nursing program(s) within the NEU at the off-campus instructional site.4

Yes

Procedure 1

Required for first two off-campus instructional sites3,4
Note: All new off-campus instructional sites must be reported whether or not a focused visit is required

Establishing a new off-campus instructional site at which students can obtain 25% to 49% of the number of nursing credit/quarter/clock hours required for completion of a nursing program

No

Procedure 2

No

Prior to implementation

Establishing a new off-campus instructional site at which students can obtain 1% to 24% of the number of nursing credit/quarter/clock hours required for completion of a nursing program

N/A

N/A

N/A

N/A

Relocating a currently approved branch campus or off-campus instructional site serving the same geographic region where nursing program is offered

No

Procedure 2

Possible4

Prior to implementation

Relocating a nursing education unit

Yes

Procedure 2

Possible

Four months prior to implementation of the change

Adding a permanent branch campus or off-campus instructional site at which the governing organization is conducting a teach-out for students of another governing organization that has ceased operating before all students enrolled in an accredited or non-accredited nursing program have completed the nursing program of study. Once approved to offer any nursing program at a branch campus within the nursing education unit (NEU) per ACEN records, approval is not required to offer any subsequent nursing program(s) within the NEU at the branch campus.4

ACEN is Title IV gatekeeper – Yes

Procedure 1

Required, for each branch campus
Required, for first two off-campus instructional sites3,4

Four months prior to implementation of the change

ACEN is not Title IV gatekeeper – Yes

Procedure 1

Possible for each branch campus4
Required, for first two off-campus instructional sites3,4
Note: All new branch campuses and all new off-campus instructional sites must be reported whether or not a focused visit is required

Inactivating a branch campus or off-campus instructional site where a nursing program or nursing program option is offered

No

Procedure 2

No

Four months prior to implementation of the change

Closing an approved branch campus or off-campus instructional site where a nursing program is offered

No

Procedure 3
See ACEN Policy #16

No

Four months prior to implementation of the change

Reactivating a branch campus or off-campus instructional site where a nursing program or nursing program option is offered

No

Procedure 2

No

Four months prior to implementation of the change

ENROLLMENT

An increase in total enrollment of 50% or greater by headcount in one institutional fiscal year for any ACEN-accredited nursing program

Yes

Procedure 1

Possible

Four months prior to implementation of the change

An increase in total enrollment of 25-49% by headcount in one institutional fiscal year for any ACEN-accredited nursing program

Yes

Procedure 2

Possible

Four months prior to implementation of the change

An increase in total enrollment of 50% or greater by headcount in one academic year for the governing organization

ACEN is Title IV gatekeeper – Yes

Procedure 1

Possible

Four months prior to implementation of the change

ACEN is not Title IV gatekeeper – No

Procedure 2

MISSION/GOVERNANCE

Changing the ownership, legal status or form of control of the governing organization

Yes

Procedure 1

Required, if ACEN is Title IV gatekeeper

Four months prior to implementation

Possible if ACEN is not Title IV gatekeeper

Merging/consolidating two or more governing organizations/nursing programs

Yes

Procedure 1

Yes

Four months prior to implementation

Substantial change in the established mission or objectives of the governing organization or its programs (this does not include a revision/update in the mission statement)

Yes

Procedure 1

Required, if ACEN is Title IV gatekeeper

Four months prior to implementation

Possible, if ACEN is not Title IV gatekeeper

A change in the nurse administrator

No

Procedure 4

No

Within 30 calendar days after permanent or interim nurse administrator assumes duties
/responsibilities

Significant change in the organizational structure of the nursing education unit that would place a nursing program in non-compliance with ACEN Standards and Criteria

Yes

Procedure 1

Possible

Four months prior to implementation of the change

The governing organization’s most recently published Financial Responsibility Composite Score being 1.0 or less2
Note: Only applies to governing organizations that are proprietary or private nonprofit.

No

Procedure 4

Possible

Within 60 calendar days of the governing organization knowing composite score 1.0 or less

Teach-Out Plan or Teach-Out Agreement; see ACEN Policy #36

N/A

Procedure 4

Possible

Within 60 calendar days of the program receiving notification

CONSORTIA/CONTRACTUAL AGREEMENTS

Entering into a contractual or consortium relationship with an entity to jointly offer all or part of a nursing program

Yes

Procedure 1

Possible

Four months prior to implementation of the change

Entering into a relationship under 34 CFR 668.5 which an entity not certified to participate in Title IV, HEA offers more than 25% and up to 50% of the clock hours or credit hours required for completion of a nursing program2

Yes

Procedure 1

Possible

Four months prior to implementation of the change

1 Required template forms, additional information, and guidelines for submission located on the ACEN website at: https://www.acenursing.org/resources-reporting-substantive-change/.
2 The Board of Commissioners has delegated to the Chief Executive Officer the responsibility and authority to approve or disapprove this type of request.
3 When a governing organization/nursing program initiates its third, fourth, fifth, sixth, etc. off-campus instructional site; has successfully completed at least one cycle of continuing accreditation; currently is not on continuing accreditation with warning or continuing accreditation for good cause or has not been placed on continuing accreditation with warning or continuing accreditation for good cause over the prior three academic years; and is under a provisional certification as provided in 34 CRF 668.1, then the governing organization/nursing program does not need to apply to the ACEN for approval of these subsequent off-campus instructional sites prior to implementation. However, the governing organization/nursing program must report these changes to the ACEN within 30 calendar days of implementation of the third, fourth, fifth, sixth, etc. off-campus instructional site. Required template forms, additional information, and guidelines for submission are located on the ACEN website at: https://www.acenursing.org/resources-reporting-substantive-change/.
4 The ACEN may, at its discretion, conduct a focused visit to any branch campus or off-campus instructional site at the time the governing organization/nursing program reported the implementation of the branch campus or off-campus instructional site for any nursing program or the ACEN becomes aware of the use of a location for any nursing program. Consideration will be given to whether the governing organization/nursing program has previously demonstrated a record of effective oversight of any nursing program at a branch campus and/or off-campus instructional site. All new branch campuses and off-campus instructional sites must be reported whether or not a focused visit is required.
5 Applies only when the ACEN is the Title IV gatekeeper for nursing programs that currently are on continuing accreditation with warning or continuing accreditation for good cause OR have been placed on continuing accreditation with warning or continuing accreditation for good cause over the prior three academic years or the governing organization/nursing program is under a provisional certification as provided in 34 CFR 668.13, the governing organization/nursing program must receive prior approval for this type of substantive change (Procedure 1).

REVIEW PROCEDURES FOR A SUBSTANTIVE CHANGE
There are four procedures for addressing the different types of substantive changes.

  1. Procedure 1: Review of a substantive change requiring the approval of the Board of Commissioners or Chief Executive Officer prior to implementation.
  2. Procedure 2: Review of a substantive change requiring notification prior to implementation.
  3. Procedure 3: Review of the closing of a nursing program or closing of an off-campus instructional site or branch campus where a nursing program is offered; approval prior to implementation, teach-out agreement, and/or teach-out plan required.
  4. Procedure 4: Review of a substantive change requiring ACEN notification.

COMMISSION RESPONSIBILITIES
The Board of Commissioners makes all final accreditation decisions for nursing programs wherever a nursing program is located or however a nursing program is delivered. ACEN staff, as delegated by the Board of Commissioners, are responsible for reviewing all substantive changes that occur, determining whether the change has affected the quality of the nursing program, referring programs to the Board of Commissioners or Chief Executive Officer as appropriate, and assuring the public that all aspects of the nursing program continue to meet the Standards and Criteria.
The ACEN is recognized by the U.S. Department of Education as an agency whose accreditation enables nursing programs to seek eligibility to participate in Title IV nursing programs. To maintain its recognition with the U.S. Department of Education, the ACEN has incorporated federal requirements into its substantive change policy and procedures. Some of those requirements specify that a nursing education unit seek and receive approval prior to the initiation of a substantive change so that the change can be included in the nursing program’s scope of accreditation.

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:
Board of Commissioners

  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 ACEN Policy #19 Focused Visit.
    1. If the ACEN is the program’s Title IV gatekeeper and the program is adding a branch campus or adding a 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.
    2. If the focused visit is authorized for reasons other than listed above, the focused visit may be completed up to 18 months after the implementation of the substantive change.
  1. Approve the substantive change and require a written report about the status of the implementation of the substantive change within a specified timeframe.
  2. 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
    1. Accept the additional information and approve the substantive change; no further information is required; or
    2. 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 ACEN Policy #19 Focused Visit.
    3. Deny the substantive change. This is not an appealable action.
    4. 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 ACEN Policy #19 Focused Visit.
  1. Deny the substantive change. This is not an appealable action.
  2. 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 ACEN Policy #19 Focused Visit.

Chief Executive Officer
Substantive changes categorized as Procedures 2, 3, and 4 reviews, the ACEN Chief Executive Officer may take the following actions:

  1. Accept or not accept the required documentation; 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
    1. Accept or not accept the additional information after review; or
    2. Refer the substantive change submission and additional information to the Board of Commissioners for consideration and possible further action.
  1. Refer the substantive change request to the Board of Commissioners for consideration and possible further action.

Policy #14 History
Revised July 2015
Revised November 2018
Revised July 2020
Revised May 2021
Edited June 2022