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 one or more of the following:

  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.
  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 may act upon concerns from a recognized state or federal agency. However, the ACEN will not interpose itself as a reviewing authority in individual matters such as (but not limited to):

  1. Admission.
  2. Grades.
  3. Granting or transferability of credits.
  4. Application of academic policies.
  5. Fees or other financial matters.
  6. Disciplinary matters.
  7. Contractual rights and obligations.
  8. Personnel decisions.
  9. Similar matters.

The ACEN will also not:

  1. seek any type of compensation, damages, readmission, or other redress on an individual’s behalf.
  2. respond to or take action upon any complaint that is defamatory, hostile, or profane.
  3. involve itself in collective bargaining disputes.
  4. accept complaints about individuals.

An individual interested in submitting information regarding a nursing program to be considered during an upcoming initial or continuing accreditation review should follow 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 Policy #8 or Policy #20 as appropriate to the circumstance.

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. 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 since the last ACEN accreditation visit (or from the time candidacy was achieved for programs seeking initial accreditation). This record must be available to the ACEN upon request. The record(s) or the nursing program will be examined by the ACEN as part of the program’s initial or continuing accreditation review. The ACEN will not review or act upon a complaint formally filed with the ACEN more than one year after the completion of the governing organization’s and/or nursing program’s grievance procedures.

The ACEN will not consider a complaint while 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 any individuals, including nursing students, the ACEN may at its discretion choose to proceed with its review.

Records of single complaints will be maintained by the ACEN in accordance with Policy #12. 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.

Submitting a Complaint

  1. All complaints must be submitted in English using the ACEN’s official online Complaint Form, which must be completed in its entirety, including any supporting documents. Click here to access the ACEN’s official Complaint Form.
  2. The ACEN will not review or act upon unsubstantiated anonymous complaints.
  3. The ACEN will not 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, coworker, friend, or attorney of a complainant.
  4. The ACEN must be the original intended recipient of the complaint. The ACEN will not review or act upon complaints that are forwarded to the ACEN.
  5. The ACEN will not accept or discuss complaints via telephone.

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.
    3. it demonstrates the governing organization’s and/or nursing program’s noncompliance with one or more of the following:
      1. The Standards and Criteria.
      2. An ACEN policy.
      3. The governing organization’s and/or nursing program’s own published policy as said policy relates to the Standards and Criteria.
      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 staff 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 board meeting. Following that meeting, the complainant and the 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 board meeting. Following that meeting, the complainant and the nurse administrator will be notified of the board’s decision.

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

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

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