ACEN Accreditation Manual – Policy 20

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

ACEN Accreditation Manual – Section II Policies

POLICY #20
Complaints Against an Accredited Program

The ACEN will only act upon substantiated complaints against an accredited program that indicate:

  1. A governing organization’s and/or nursing program’s non-compliance with the Standards and Criteria;
  2. A governing organization’s and/or nursing program’s non-compliance with ACEN policy; and/or
  3. A governing organization’s and/or nursing program’s non-compliance with its own published policy as said policy relates to the Standards and Criteria.

The ACEN will not interpose itself as a reviewing authority in individual matters such as, but not limited to, admission; grades; granting or transferability of credits; application of academic policies; fees or other financial matters; disciplinary matters; contractual rights and obligations; personnel decisions; or similar matters. The ACEN will also not seek any type of compensation, damages, re-admission, or other redress on an individual’s behalf. The ACEN will not respond to or take action upon any complaint that is defamatory, hostile, or profane. In addition, the ACEN will not involve itself in collective bargaining disputes. The ACEN does not accept complaints about individuals.

In addition, the ACEN may act upon concerns from a recognized state or federal agency.

An individual interested in submitting information regarding a nursing program to be considered during an upcoming initial or continuing accreditation review should follow ACEN Policy #8 Opportunities for Third-Party Comments on Programs Scheduled for Evaluation. The ACEN reserves the right to review and act upon incoming complaints or third-party comments under either ACEN Policy #8 or Policy #20 as appropriate to the circumstance.

Records of single complaints will be maintained by the ACEN for eight years. If a number of single complaints suggest a pattern of concern not evident from any single complaint, the ACEN may renew its consideration of a matter for whatever action may be appropriate.

The ACEN expects an individual to attempt to resolve an issue through the governing organization’s and/or nursing program’s own published grievance policy/procedures (if applicable) before submitting a complaint to the ACEN. Therefore, an individual must use all available grievance and means of appeal within the governing organization and/or nursing education unit before filing a complaint with the ACEN. The ACEN will not consider a complaint while institutional proceedings or litigation appertaining thereto are ongoing. However, if the ACEN determines that the complainant raises issues so immediate that a delay may jeopardize the nursing program’s accreditation status or cause harm to nursing students, the ACEN may, at its discretion, choose to proceed with its review. The ACEN will not review or act upon a complaint to which the governing organization’s and/or nursing program’s published grievance policy/procedures apply if it is formally filed with the ACEN more than one year after the completion of the policy/procedures.

The ACEN will not review or act upon a complaint to which such policies/procedures do not apply if it is formally filed with the ACEN more than one year after the circumstances leading to the complaint.

SUBMITTING A COMPLAINT

  1. The complaint must be presented to the ACEN as a written, signed, and dated statement with supporting documentation. The ACEN will not review or act upon complaints that are not presented in writing.
  2. All complaints must be submitted using the ACEN’s official Complaint Form, which must be completed in its entirety. The ACEN’s official Complaint Form is available at https://acenursing.atlassian.net/servicedesk/customer/portal/30. Complaints submitted without the official Complaint Form, completed in its entirety, will not be reviewed or acted upon.
  3. The ACEN will not review or act upon anonymous complaints, nor will it review or act upon complaints submitted by an individual or agency on behalf of another individual. For example, the ACEN will not review or act upon a complaint from a parent, spouse, child, sibling, co-worker, or friend of a complainant, or from an attorney.
  4. The ACEN must be the original intended recipient of the complaint and will not review or act upon complaints that are forwarded to the ACEN.
  5. The ACEN will not accept or discuss complaints via telephone.
  6. All written materials, including the submitted Complaint Form, the required supporting documentation, and any other printed materials, must be presented in English.

Each governing organization and nursing education unit is required to have in place written student complaint policies and procedures that are reasonable, fairly administered, and well publicized. All written student complaints must be resolved in a timely manner. In accordance with federal regulations, each governing organization and nursing education unit must maintain a record of complaints received. This record must be available to the ACEN upon request. The record(s) for the nursing program will be examined by the ACEN as part of the program’s initial or continuing accreditation review.

ACEN PROCEDURE FOR PROCESSING COMPLAINTS

  1. The ACEN will acknowledge a complaint within 15 business days of its receipt.
  2. Within 60 business days after acknowledging receipt of the complaint, the ACEN staff will review the complaint and determine whether:
    1. it is related to the program’s accreditation status,
    2. it is within the scope of ACEN policy, and/or
    3. it demonstrates the governing organization’s and/or nursing program’s noncompliance with:
      1. the Standards and Criteria,
      2. an ACEN policy, and/or
      3. the governing organization’s and/or nursing program’s own published policy as said policy relates to the Standards and Criteria, and
    4. there is adequate evidence in support of the allegations made in the complaint.
  3. If the complaint does not have sufficient substance to warrant further review, the ACEN will communicate this to the complainant, in writing, within 15 business days of reaching this conclusion.
  4. If the complaint has sufficient substance to warrant further review, the ACEN will make every effort to expedite its review; however, the time required to conduct its review may vary considerably depending on the circumstances and nature of the complaint.
  5. When a complaint is reviewed further, a copy of the complaint will be forwarded to the nurse administrator of the nursing program, who will be asked to respond to the ACEN within 20 business days. Upon receipt of a response from the nurse administrator, the ACEN reserves the right to request additional materials, as needed, from the complainant and/or nurse administrator.
  6. If there is insufficient evidence of non-compliance, the complaint will not be processed further. The decision of the ACEN Chief Executive Officer is final, and the complainant and nurse administrator will be notified of this outcome.
  7. If there appears to be sufficient evidence of non-compliance or if the ACEN staff are unable to determine compliance, the following actions may be taken by the ACEN Chief Executive Officer (the complainant and nurse administrator will be notified of this outcome):
    1. The complaint may be forwarded directly to the ACEN Board of Commissioners for review and action.
    2. The ACEN Chief Executive Officer may authorize a Focused Visit to evaluate the governing organization/nursing program. The Focused Visit Team will examine documents and interview institutional personnel to analyze and make a judgment regarding compliance, after which they will prepare a Focused Site Visit Report. This Report will be forwarded to the ACEN Board of Commissioners for review and action at the next meeting of the Board. Following that meeting, the complainant and nurse administrator will be notified of the Board’s decision.
    3. The complaint allegations may be reviewed as part of an upcoming scheduled visit to the nursing program. The peer evaluators will examine documents and interview institutional personnel to analyze and make a judgment regarding compliance, after which they will prepare a Site Visit Report. This Report will be forwarded to the ACEN Board of Commissioners for review and action at the next meeting of the Board. Following that meeting, the complainant and nurse administrator will be notified of the decision of the Board.

For items 7a, 7b, or 7c above, the decision of the ACEN Board of Commissioners is final unless appealable as delineated in ACEN Policy #10 Appeal Process and Submission and Review of New Financial Information Subsequent to Adverse Action.

Policy #20 History
Revised November 2015
Edited March 2019
Edited January 2023

Return to Policies List

Back to top