ACEN Accreditation Manual – Policy 3

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

ACEN Accreditation Manual – Section II Policies

POLICY #3 Eligibility for Initial and Continuing Accreditation

To be eligible for initial or continuing accreditation, the governing organization and nursing program must demonstrate that it meets or continues to meet all the eligibility and continuing eligibility requirements of the ACEN.

Governing Organization/Institution Seeking Initial Accreditation Eligibility Requirements

  1. The governing organization/institution is legally authorized to provide a postsecondary education program in the state or country in which the governing organization/institution and nursing program is physically located.
  2. The governing organization/institution is legally authorized to grant the credential (degree, diploma, or certificate) for the nursing program seeking accreditation.
  3. The governing organization/institution is accredited or approved to pursue accreditation by a governing organization/institutional accrediting agency recognized by the ACEN; however, this does not apply to programs outside the U.S. or its territories.
  4. For governing organizations/institutions included in The ACEN Will Accredit A Nursing Program When… that do not hold governing organization/institutional accreditation by a governing organization/institutional accrediting agency recognized by the ACEN:
      1. The governing organization/institution must be approved to pursue accreditation by a governing organization/institutional accrediting agency recognized by the ACEN.
      2. The governing organization/institution must be accredited with a governing organization/institutional accrediting agency recognized by the ACEN before the ACEN Board of Commissioners makes its initial accreditation decision for the nursing program(s) seeking initial accreditation with the ACEN.
  1. For governing organizations/institutions included in point 2 of The ACEN Will Accredit A Nursing Program When… that do not hold or are ineligible to hold governing organization/institutional accreditation by a governing organization/institutional accrediting agency recognized by the ACEN, the governing organization/institution must be approved by a supervisory state education department, public school system, or district before the ACEN Board of Commissioners makes its initial accreditation decision for the nursing program(s) seeking initial accreditation with the ACEN.
  2. The nurse administrator of the nursing program is responsible for immediately informing the ACEN Chief Executive Officer in writing of any change of status with any agency that accredits and/or approves the governing organization/institution. The notification must occur before the ACEN Board of Commissioners makes its initial accreditation decision.

Governing Organization/Institution Seeking Continuing Accreditation

  1. The governing organization/institution must continuously hold legal authorization to provide a postsecondary education program in the state or country in which the governing organization/institution and nursing program are physically located.
  2. The governing organization/institution must continuously hold legal authorization to grant the credential (degree, diploma, or certificate) for the nursing program seeking accreditation.
  3. For governing organizations/institutions included in the section below, the governing organization/institution must continuously hold an accredited status with an ACEN-recognized governing organization/institutional accrediting agency.
  4. For governing organizations/institutions included in point 2 of the section below, the governing organization/institution must continuously hold approval by a supervisory state education department, public school system, or district.
  5. The nurse administrator of the nursing program is responsible for immediately informing the ACEN Chief Executive Officer in writing of any change of status with any agency that accredits and/or approves the governing organization/institution. The notification must occur before the ACEN Board of Commissioners makes its continuing accreditation decision.

The ACEN Will Accredit a Nursing Program When…

  1. It is administered by a college, university, or technical/vocational governing organization/institution that is part of the system of higher education, grants a diploma, certificate, associate degree, baccalaureate degree, master’s degree, post-master’s certificate, clinical doctorate degree in nursing, or DNP specialist certificate, and the college, university, or technical/vocational governing organization/institution holds governing organization/institutional accreditation through an ACEN-recognized governing organization/institutional accrediting agency.
  2. It is administered by a vocational, technical, or career school, public school system, or district, grants a postsecondary certificate, and the vocational, technical, or career school, public school system, or district holds governing organization/institutional accreditation through an ACEN-recognized governing organization/institutional accrediting agency or the governing organization is supervised by a state education department, public school system, or district.
  3. It is administered by a hospital, grants a diploma, certificate, associate degree, baccalaureate degree, master’s degree, post-master’s certificate, clinical doctorate in nursing degree, or DNP specialist certificate, and the hospital holds governing organization/institutional accreditation through an ACEN-recognized governing organization/institutional accrediting agency. Programs outside the U.S. or its territories must be administered by a college, university, or a technical or vocational governing organization/institution that is a part of a system of higher education as well as grant a diploma, certificate, associate degree, baccalaureate degree, master’s degree, post-master’s certificate, clinical doctorate degree in nursing, or DNP specialist certificate.
  4. It is administered by an independent college, university, or a technical or vocational governing organization/institution, grants a diploma, certificate, associate degree, baccalaureate degree, master’s degree, post-master’s certificate, clinical doctorate in nursing degree, or DNP specialist certificate, and the college, university, or technical or vocational governing organization/institution holds governing organization/institutional accreditation through an ACEN-recognized governing organization/institutional accrediting agency.

Programs outside the U.S. or its territories must be administered by a college, university, or technical or vocational governing organization/institution that is a part of a system of higher education and grant a diploma, certificate, associate degree, baccalaureate degree, master’s degree, post-master’s certificate, clinical doctorate degree in nursing, or DNP specialist certificate.

If the nursing program is administered by a vocational, technical, or career school or public school system or district and grants a postsecondary certificate, the governing organization/institution and nursing program may use ACEN accreditation to establish eligibility to participate in Title IV programs of the Higher Education Act of 1965 as amended. If the governing organization’s/institution’s accrediting agency is recognized by the U.S. Department of Education to establish Title IV eligibility, the ACEN may not be used to establish Title IV eligibility.

If the nursing program is administered by a hospital and grants a diploma, certificate, associate degree, baccalaureate degree, master’s degree, post-master’s certificate, clinical doctorate in nursing, or DNP specialist certificate, the governing organization/institution and nursing program may use ACEN accreditation to establish eligibility to participate in Title IV programs of the Higher Education Act of 1965 as amended. If the governing organization’s/institution’s accrediting agency is recognized by the U.S. Department of Education to establish Title IV eligibility, the ACEN may not be used to establish Title IV eligibility. Title IV does not apply to programs outside the U.S. or its territories.

Nursing Program Initial Accreditation Requirements

  1. The nursing program must be approved without qualification, except new programs that may have a provisional status related to having no graduates, by the state or country agency(ies) that has/have legal authority for education programs in nursing. This is not applicable to those programs in nursing over which a state or country regulatory agency that has legal authority for education programs in nursing has no jurisdiction (e.g., selected master’s degree programs or programs admitting previously licensed registered nurses).
  2. The nurse administrator of the nursing program is responsible for immediately informing the ACEN Chief Executive Officer in writing of any change of status with any state or country agency that has legal authority for education programs in nursing. The notification must occur before the ACEN Board of Commissioners makes its initial accreditation decision.

Nursing Program Continuing Accreditation Requirements

  1. The nursing program must be approved with or without qualification by the state or country agency(ies) that has/have legal authority for education programs in nursing. This is not applicable to those programs in nursing over which a state or country regulatory agency that has legal authority for education programs in nursing has no jurisdiction (e.g., selected master’s degree programs or programs admitting previously licensed registered nurses).
  2. The nurse administrator of the nursing program is responsible for immediately informing the ACEN Chief Executive Officer in writing of any change of status with any state or country agency that has legal authority for education programs in nursing. The notification must occur before the ACEN Board of Commissioners makes its continuing accreditation decision.

Recommendations for Governing Organizations, Institutions, and Nursing Programs Seeking Initial Accreditation

  1. For nursing programs without previous graduates, the program should seek approval to pursue ACEN accreditation and host the initial accreditation site visit within a timeframe that would facilitate that all students are graduates of an accredited program.
  2. For nursing programs with previous graduates, the program should seek approval to pursue ACEN accreditation and host the initial accreditation site visit as soon as possible to facilitate students graduating from an accredited program.

Recommendations for Governing Organizations, Institutions, and Nursing Programs Seeking Initial or Continuing Accreditation

  1. If a governing organization offers the same certificate or degree nursing program with more than one option, then that nursing program and all its options must be reviewed in its entirety for initial or continuing accreditation by the ACEN. All nursing program options that lead to the same degree or certificate within a governing organization/institution must be accredited by the ACEN for any one of the options to be accredited. The nursing program may not select individual options within the same certificate or degree to be reviewed for accreditation.
Example 1  
The accreditation of a master’s degree program that includes several options such as Family Nurse Practitioner (FNP), Adult Gerontology Acute Care Nurse Practitioner (AGACNP), Nurse Education, and Nurse Leader must be inclusive of all options. The nursing program may not select only the FNP and AGACNP options to be reviewed for accreditation.   Rationale: Students graduate from a master’s degree program, not an option; therefore, the accreditation applies to the entire nursing program.
Example 2  
The accreditation of an associate degree program that includes two options such as prelicensure and LPN-to-RN must be inclusive of all options. The nursing program may not select only the prelicensure option to be reviewed for accreditation.   Rationale: Students graduate from an associate degree program, not an option; therefore, the accreditation applies to the entire nursing program.
  1. If a governing organization/program offers a graduate-level certificate(s) composed of only the specialty courses for an option(s), the ACEN will automatically include the graduate-level certificate program option(s) in its review of the graduate-level degree program in the accreditation process.
Example 3  
A governing organization/program seeks accreditation of a master’s program that includes several options such as Family Nurse Practitioner (FNP), Adult Gerontology Acute Care Nurse Practitioner, Nurse Educator, and Nurse Leader, and the governing organization/program offers a certificate(s) composed of only the specialty courses from an option(s) such as FNP, then the ACEN will automatically include the certificate program option(s) in its review of the degree program in the accreditation process.   Rationale: The options that compose the certificate(s) are a subset of the degree program, and the accreditation applies to the entire nursing program, including the certificate(s).
  1. The ACEN supports models whereby one nursing program is “nested” within another nursing program, which facilitates graduates being able to progress seamlessly from one level of licensure to another level of licensure such as practical nursing to registered nursing. A “nested” practical nursing program is an educational program leading to a specific level of licensure and must have its own program-specific end-of-program student learning outcomes. Graduates from a practical nursing program embedded within an ACEN-accredited registered nursing program are not graduates of an ACEN-accredited practical nursing program unless the practical nursing program holds ACEN accreditation specifically for the practical nursing program.
  2. If a governing organization offers the same certificate or degree nursing program at more than one location within the same nursing education unit, then that nursing program and all locations must be reviewed in its entirety for initial or continuing accreditation by the ACEN. The nursing program may not select individual locations within the same certificate or degree nursing program to be included in the ACEN accreditation.
  3. In accordance with federal regulation 34 CFR §602.28 and consistent with ACEN policy:
    1. The ACEN may not grant initial accreditation or continuing accreditation to a governing organization/institution or a nursing program offered by a governing organization/institution if the ACEN knows or has reasonable cause to know that a governing organization/institution or a nursing program is the subject of:
    1. A pending or final action brought by a state agency to suspend, revoke, withdraw, or terminate a governing organization’s/institution’s legal authority to provide postsecondary education in the state.
    2. A decision by a recognized agency to deny accreditation or pre-accreditation.
    3. A pending or final action brought by a recognized accrediting agency to suspend, revoke, withdraw, or terminate a governing organization’s/institution’s accreditation or pre-accreditation.
    4. A probation or an equivalent status imposed by a recognized agency.
    1. The ACEN may grant initial accreditation or continuing accreditation to a governing organization/institution or nursing program only if ACEN provides to the Secretary of the U.S. Department of Education within 30 calendar days of its action a thorough and reasonable explanation consistent with the Standards and Criteria why the action of the other body does not preclude the granting of initial accreditation or continuing accreditation by the ACEN.
    2. If the ACEN learns that a governing organization/institution or nursing program it accredits is the subject of an adverse action by another recognized accrediting agency or has been placed on probation or an equivalent status by another recognized agency, the ACEN must promptly review its accreditation of the governing organization/institution or nursing program to determine if it should also take adverse action or place the governing organization/institution or nursing program on conditions or warning.
    1. See Policy #14 Reporting Substantive Changes and Policy #18 Accreditation Status of the Governing Organization for details regarding a negative or adverse action by an appropriate governing organization/institutional accrediting agency.

Policy #3 History
Revised July 2015
Revised October 2016
Revised July 2017
Revised November 2018
Revised July 2020
Edited June 2023

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