ACEN Accreditation Manual – Policy 19


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ACEN Accreditation Manual – Section II Policies

POLICY #19
Focused Site Visit


The ACEN Board of Commissioners or ACEN Chief Executive Officer may determine a focused site visit is warranted in order to review significant accreditation-related information disclosed about a program as a result of:

  1. A substantive change;
  2. Information revealed about a nursing program between periods of scheduled review;
  3. Information received from the governing organization’s accrediting body related to an adverse action;
  4. Information received from the nursing program’s state regulatory agency for nursing related to a change in its status;
  5. Information revealed about a nursing program during the Evaluation Review Panel process;
  6. Information received from the U.S. Department of Education regarding a governing organization’s/nursing program’s compliance responsibilities under Title IV of the Higher Education Act such as information related to a governing organization’s/nursing program’s most recent student loan default rates, the results of financial or compliance audits, program reviews, and any other information that may be provided by the U.S. Department of Education.

The Standards and Criteria pertinent to the reason for the focused site visit will be reviewed. Professional staff will determine the Standards and Criteria to be reviewed. The nursing program must prepare a Focused Visit Report based on the Standards and Criteria identified and submit the Report to the site visitors and ACEN six weeks before the focused site visit; the Focused Visit Report is the foundation for review of compliance with the identified Standards and Criteria. See the ACEN Guidelines for Written Reports and Written Report Instructions Report Type: Focused Visit Report available on the ACEN website. The focused site visit is typically 1–2 days in length.

The ACEN Chief Executive Officer reserves the right to:

  1. Have an ACEN staff member accompany a focused site visit team. If an ACEN staff member accompanies a focused site visit team, the staff member would offer guidance to the peer evaluators. The governing organization/nursing program is responsible for all costs of the staff member accompanying the focused site visit team.
  2. Have an ACEN staff member serve on a focused site visit team. If an ACEN staff member serves on a focused site visit team, the staff member would serve as a peer evaluator. The governing organization/nursing program is responsible for all costs of the staff member serving on the focused site visit team.

Following the focused site visit, the Board of Commissioners may take one of the following actions:

  1. Affirm the program’s accreditation status and date of the next scheduled visit; no further information is requested.
  2. Change the date of the program’s next scheduled visit to a date earlier than previously scheduled. This is not an appealable action.
  3. Change the program’s accreditation status to one of the following statuses.
    1. Continuing accreditation with conditions
    2. Continuing accreditation with warning
    3. Continuing accreditation for good cause
    4. Deny continuing accreditation and remove the program from the list of accredited programs. This is an appealable action. See ACEN Policy #10 Appeal Process and Submission and Review of New Financial Information Subsequent to Adverse Action.

See ACEN Policy #4 Types of Commission Actions for Continuing and Initial Accreditation for potential decisions and maximum monitoring period – conditions, warning, and good cause.

Focused Site Visit

The ACEN may schedule either an in-person or virtual focused site visit. The ACEN CEO reserves the right and has the authority to determine when to conduct an in-person site visit and when to conduct a virtual focused site visit. While the ACEN staff will seek input from the governing organization/nursing program representatives, the CEO’s determination is not appealable.

A virtual focused site visit shall use an engaged, interactive format; it shall not rely solely on a review of documents or exchanges of emails. The rigor, quality, and process of the virtual focused site visit as well as the opportunity for the governing organization/nursing program to provide evidence as well as verify, clarify, and/or amplify evidence must be comparable to an in-person site visit. Therefore, a virtual focused site visit requires the use of video or web conferencing tools, which allow real-time synchronous communication among participants and visual display of individuals, groups, documents, and/or physical spaces.

When a virtual focused site visit is conducted by the ACEN, all or some of the peer evaluators are not physically present at the governing organization/nursing program. A virtual focused site visit will be scheduled accordingly to accommodate time zones of all ACEN peer evaluators conducting the virtual visit and the time zone of the nursing program hosting the visit, with the understanding that adjustments to schedules will be needed of all participants involved in the visit.

Full or Partial Virtual Focused Site Visits

In a full virtual focused site visit, all ACEN peer evaluators conduct their review of the governing organization/nursing program using real-time synchronous video or web conferencing tools, which can be supplemented by telephonic conferencing tools.

In a partial virtual focused site visit, one or more ACEN peer evaluators conduct their review of the governing organization/nursing program using real-time synchronous video or web conferencing tools, which can be supplemented by telephonic conferencing tools, while one or more other ACEN peer evaluators conduct their review of the governing organization/nursing program in person.

Eligibility for a Virtual Focused Site Visit

  1. The ACEN may determine that any governing organizations/nursing program seeking continuing accreditation with the ACEN is eligible for a virtual focused site visit. Continuing accreditation includes all governing organizations/nursing programs with the current accreditation status of continuing accreditation, continuing accreditation with conditions, continuing accreditation with warning, or continuing accreditation for good cause.
  2. Under the direction of the CEO, ACEN staff will review a governing organization’s/nursing program’s accreditation history, annual reports, and the reason for considering a virtual focused site visit to determine whether a governing organization/nursing program is eligible for a virtual focused site visit.
  3. For procedure 1 substantive changes where 100% of the peer evaluators conducted their review virtually, the ACEN must conduct a follow-up in-person site visit to the governing organizations/nursing programs (though not necessarily a full peer-review in-person site visit) within a reasonable period of time following the virtual focused site visit.
  4. For procedure 2, 3, or 4 substantive changes where 100% of the peer evaluators conducted their review virtually, the ACEN may conduct a follow-up in-person site visit to the governing organizations/nursing programs (though not necessarily a full peer-review in-person site visit) within a reasonable period of time following the virtual focused site visit.

Evidence, Technology Infrastructure, Facilities, and Support Services

  1. All virtual focused site visit activities shall be scheduled using the real-time synchronous virtual meeting system in use by the ACEN.
  2. The governing organization/nursing program is responsible for ensuring that its technology infrastructure, facilities, and support services can accommodate a fully engaged, real-time interactive virtual focused site visit.
  3. The governing organization/nursing program must conduct a technology test prior to the virtual focused site visit to demonstrate to the ACEN’s satisfaction that it has adequate technology infrastructure and support services to conduct a virtual focused site visit that meets the ACEN’s requirements, including making 100% of the program’s written report inclusive of the required appendices and supporting evidence available virtually to the ACEN peer evaluators and the ACEN.
  4. The governing organization/nursing program must ensure that there are adequate meeting spaces (facilities) for governing organization/nursing program representatives to meet with the ACEN peer evaluators, including simultaneous meetings as needed with individuals and groups.
  5. The governing organization/nursing program must provide virtual access (e.g., as PDFs on a flash drive or through a learning management system) to documentation/evidence that is comparable and sufficient to the access normally found during an in-person site visit to demonstrate compliance with the ACEN Standards and Criteria. The governing organization/nursing program must provide:
    1. Six weeks before the visit, peer evaluators with viewer access to the program’s written report inclusive of the required appendices and virtual supporting evidence.
    2. Any additional information the peer evaluators request before the visit.
    3. Any additional information the peer evaluators request during the visit.

See the ACEN Guidelines for Written Reports available on the ACEN website for additional information.

  1. The governing organization/nursing program must provide virtual access to all interviewees (simultaneously as needed with individuals and groups) that is comparable and sufficient to the access normally found during an in-person site visit to demonstrate compliance with the ACEN Standards and Criteria.

ACEN Reserve Rights and Applicability to Current Policies

  1. Unless specifically stated in this document, all ACEN policies, processes, procedures, practices, and protocols apply and remain in force.
  2. All applicable focused site visit accreditation fees, policies, processes, procedures, practices, and protocols shall be the same as for an in-person focused site visit, full virtual site visit, and partial virtual site visit.
  3. ACEN reserves the right to cancel a full or partial virtual focused site visit at any time prior to or during the scheduled visit and schedule a full in-person site visit instead. An in-person site visit will be scheduled within a reasonable period of time following the canceled virtual focused site visit.
  4. If there is a technology failure that significantly impairs the peer evaluators’ ability to have an engaged, real-time interactive review, then the team chair shall terminate the virtual focused site visit immediately, and the governing organization/nursing program cannot be visited/accredited using the virtual focused site visit format. An in-person site visit will be scheduled within a reasonable period of time following the terminated virtual focused site visit.
  5. If the team chair and team members determine that the program’s written report inclusive of the required appendices and supporting evidence available virtually are inadequate and the inadequacy significantly impairs their ability to conduct a review comparable to an in-person site visit, then the team chair, in consultation with ACEN staff (before or during the virtual focused site visit), shall terminate the virtual focused site visit, and the governing organization/nursing program cannot be visited/accredited using the virtual focused site visit format. An in-person site visit will be scheduled within a reasonable period of time following the terminated virtual focused site visit.
  6. The governing organization/nursing program shall not record (audio or video) any portion of the virtual focused site visit. Based on ACEN Policy #31 Integrity, if evidence of recording is discovered, the team chair shall terminate the virtual focused site visit immediately, and the governing organization/nursing program cannot be visited/accredited using the virtual focused site visit format. Per Policy #31, if evidence of recording is discovered, it may adversely affect the governing organization’s/nursing program’s accreditation status with the ACEN.

Policy #19 History
Revised July 2015
Edited March 2019
Revised July 2020

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