ACEN Accreditation Manual – Policy 4

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

ACEN Accreditation Manual – Section II Policies

POLICY #4
Types of Commission Actions for Initial and Continuing Accreditation

INITIAL ACCREDITATION

The ACEN Board of Commissioners may grant initial accreditation or deny initial accreditation.

Granted

Initial accreditation of a nursing program is granted when the ACEN Board of Commissioners determines a program demonstrates compliance with all Accreditation Standards. The next review process shall be in five years from the accreditation cycle that resulted in the ACEN Board of Commissioners granting initial accreditation.

Denied

Initial accreditation of a nursing program is denied when the ACEN Board of Commissioners determines a program does not demonstrate compliance with all Accreditation Standards. Denial of initial accreditation is an appealable action.

The nursing program may restart the candidacy process after the denial of initial accreditation.

  1. If a governing organization/nursing program appeals the denial of initial accreditation, the governing organization/nursing program may restart the candidacy process only after the conclusion of the appeal process.
  2. If a governing organization/nursing program pursues arbitration, the governing organization/nursing program may restart the candidacy process only after the conclusion of the arbitration process.
  3. If a governing organization/nursing program pursues legal proceedings, the governing organization/nursing program may restart the candidacy process only after the conclusion of the legal proceedings.

CONTINUING ACCREDITATION

The ACEN Board of Commissioners may grant continuing accreditation or deny continuing accreditation.

Granted

The maximum amount of time between continuing accreditation cycles shall be eight years.

  1. Continuing accreditation is granted when the ACEN Board of Commissioners determines that a nursing program is in compliance with all Accreditation Standards.
  2. Continuing accreditation with conditions is granted when the ACEN Board of Commissioners determines that a nursing program is in non-compliance with one or two Accreditation Standards. The next review and follow-up action(s) are determined by the ACEN Board of Commissioners.
  3. Continuing accreditation with warning is granted when the ACEN Board of Commissioners determines that a nursing program is in non-compliance with three or more Accreditation Standards. The next review and follow-up action(s) are determined by the ACEN Board of Commissioners.
  4. Continuing accreditation with a removal of conditions is granted when the ACEN Board of Commissioners determines that a nursing program is in compliance with the Accreditation Standards.
  5. Continuing accreditation with a removal of warning is granted when the ACEN Board of Commissioners determines that a nursing program is in compliance with the Accreditation Standards.
  6. Continuing accreditation with a removal of good cause is granted when the ACEN Board of Commissioners determines that a nursing program is in compliance with the Accreditation Standards.
  7. Continuing accreditation for good cause—see below.

Denied

A nursing program seeking continuing accreditation may be denied continuing accreditation. A nursing program denied continuing accreditation will be removed from the list of accredited programs. Denial of continuing accreditation is an appealable action.

The nursing program may start the candidacy process after the denial of continuing accreditation and removal from the list of accredited programs.

  1. If a governing organization/nursing program appeals the denial of continuing accreditation, the governing organization/nursing program may restart the candidacy process only after the conclusion of the appeal process.
  2. If a governing organization/nursing program pursues arbitration, the governing organization/nursing program may restart the candidacy process only after the conclusion of the arbitration process.
  3. If a governing organization/nursing program pursues legal proceedings, the governing organization/nursing program may restart the candidacy process only after the conclusion of the legal proceedings.

EFFECTIVE DATE

  1. Initial Accreditation
      1. Upon granting initial accreditation by the ACEN Board of Commissioners, the effective date of initial accreditation is the date on which the nursing program was approved by the ACEN as a candidate program that concluded in the ACEN Board of Commissioners granting initial accreditation.
      2. Upon denying initial accreditation by the ACEN Board of Commissioners, the effective date of denying initial accreditation will be the date on the Board of Commissioners decision letter.
  1. Continuing Accreditation
      1. Upon granting continuing accreditation by the ACEN Board of Commissioners, the effective date of granting continuing accreditation will be the date on the Board of Commissioners decision letter.
      2. Upon denying continuing accreditation by the ACEN Board of Commissioners, the effective date of denying continuing accreditation will be the date on the Board of Commissioners decision letter.

CONTINUING ACCREDITATION WITH CONDITIONS OR WARNING STATUS

Continuing Accreditation with Conditions

  1. When the ACEN Board of Commissioners determines that a nursing program is non-compliant with one or two Accreditation Standards, the ACEN Board of Commissioners may grant a nursing program continuing accreditation with conditions for up to the maximum monitoring period for the program type.

      1. When a nursing program has been granted continuing accreditation with conditions, the program must submit a Follow-Up Report addressing the Standard(s) with which the nursing program was found to be in non-compliance; a follow-up visit may be required within a specified period of time. The Follow-Up Report, or Follow-Up Report and Follow-Up Site Visit Report, and Evaluation Review Panel Summary constitute a basis for the ACEN Board of Commissioners’ decision.

The length of the monitoring period defines the ACEN Board of Commissioners’ action the next time a nursing program is reviewed. At the next review,

      1. If the ACEN Board of Commissioners determines that a nursing program is in compliance with the identified Accreditation Standards, the ACEN Board of Commissioners may grant continuing accreditation with a removal of conditions.
      2. If the ACEN Board of Commissioners determines that a nursing program is non-compliant:
    1. With one or two Accreditation Standards, the ACEN Board of Commissioners may grant continuing accreditation with conditions if the maximum monitoring period for continuing accreditation has not concluded.
    2. With three or more Accreditation Standards, the ACEN Board of Commissioners may grant continuing accreditation with warning if the maximum monitoring period for continuing accreditation has not concluded.
    3. With any Accreditation Standard, the ACEN Board of Commissioners may grant continuing accreditation for good cause if the maximum monitoring period for continuing accreditation has concluded and the program meets the requirements for good cause.
    4. With any Accreditation Standard, the ACEN Board of Commissioners may deny continuing accreditation and remove the program from the list of accredited programs, whether the maximum monitoring period for continuing accreditation has or has not concluded.

Continuing Accreditation with Warning

  1. When the ACEN Board of Commissioners determines that a nursing program is non-compliant with three or more Accreditation Standards, the ACEN Board of Commissioners may grant a nursing program continuing accreditation with warning for up to the maximum monitoring period for the program type.

      1. When a nursing program has been granted continuing accreditation with warning, the program must submit a Follow-Up Report addressing the Standard(s) with which the nursing program was found to be in non-compliance, and a follow-up visit is required within a specified period of time. The Follow-Up Report, Follow-Up Site Visit Report, and Evaluation Review Panel Summary constitute a basis for the ACEN Board of Commissioners’ decision.

The length of the monitoring period defines the ACEN Board of Commissioners’ action the next time a nursing program is reviewed. At the next review,

      1. If the ACEN Board of Commissioners determines that a nursing program is in compliance with the identified Accreditation Standards, the ACEN Board of Commissioners may grant continuing accreditation with a removal of warning.
      2. If the ACEN Board of Commissioners determines that a nursing program is non-compliant:
    1. With one or two Accreditation Standards, the ACEN Board of Commissioners may grant continuing accreditation with conditions if the maximum monitoring period for continuing accreditation has not concluded.
    2. With three or more Accreditation Standards, the ACEN Board of Commissioners may grant continuing accreditation with warning if the maximum monitoring period for continuing accreditation has not concluded.
    3. With any Accreditation Standard, the ACEN Board of Commissioners may grant continuing accreditation for good cause if the maximum monitoring period for continuing accreditation has concluded and the program meets the requirements for good cause.
    4. With any Accreditation Standard, the ACEN Board of Commissioners may deny continuing accreditation and remove the program from the list of accredited programs, whether the maximum monitoring period for continuing accreditation has or has not concluded.

Maximum Monitoring Period – Conditions and Warning

  1. The maximum monitoring period for continuing accreditation with conditions or continuing accreditation with warning for clinical doctorate, master’s, baccalaureate, associate, and diploma programs is two years from the ACEN Board of Commissioners’ determination of this accreditation status.
  2. The maximum monitoring period for continuing accreditation with conditions or continuing accreditation with warning for practical nursing programs is 18 months from the ACEN Board of Commissioners’ determination of this accreditation status.
  3. The maximum monitoring period for continuing accreditation with conditions or continuing accreditation with warning for standalone certificate nursing programs that are not a practical nursing program is determined by the length of the certificate nursing program.
    1. If the shortest period of time in which a student could complete a standalone certificate nursing program is less than 12 months, then the maximum monitoring period for continuing accreditation with conditions or continuing accreditation with warning is 12 months from the ACEN Board of Commissioners’ determination of this accreditation status.
    2. If the shortest period of time in which a student could complete a standalone certificate nursing program is at least one year but less than two years, then the maximum monitoring period for continuing accreditation with conditions or continuing accreditation with warning is 18 months from the ACEN Board of Commissioners’ determination of this accreditation status.
    3. If the shortest period of time in which a student could complete a standalone certificate nursing program is at least two years, then the maximum monitoring period for continuing accreditation with conditions or continuing accreditation with warning is two years from the ACEN Board of Commissioners’ determination of this accreditation status.

Maximum Monitoring Period – Good Cause

  1. If the ACEN Board of Commissioners determines that a nursing program has not remedied deficiencies at the conclusion of its maximum monitoring period on continuing accreditation with conditions or continuing accreditation with warning, the ACEN Board of Commissioners must (1) deny continuing accreditation and remove the nursing program from the list of accredited programs or (2) grant continuing accreditation for good cause.
    1. The maximum monitoring period for continuing accreditation for good cause for clinical doctorate, master’s, baccalaureate, associate, and diploma programs is two years from the ACEN Board of Commissioners’ determination of this accreditation status. If compliance with all the Accreditation Standards is not demonstrated within two years, the ACEN Board of Commissioners must deny continuing accreditation and remove the nursing program from the list of accredited programs.
    2. The maximum monitoring period for continuing accreditation for good cause for practical nursing programs is 30 months from the ACEN Board of Commissioners’ determination of this accreditation status. If compliance with all the Accreditation Standards is not demonstrated within 30 months, the ACEN Board of Commissioners must deny continuing accreditation and remove the nursing program from the list of accredited programs.
    3. The maximum monitoring period for continuing accreditation for good cause for standalone certificate nursing programs that are not a practical nursing program is determined by the length of the certificate nursing program.
    1. If the shortest period of time in which a student could complete a standalone certificate nursing program is 12 months, then the maximum monitoring period for continuing accreditation for good cause is 12 months from the ACEN Board of Commissioners’ determination of this accreditation status. If compliance with the Accreditation Standards is not demonstrated within 12 months, the ACEN Board of Commissioners must deny continuing accreditation and remove the nursing program from the list of accredited programs.
    2. If the shortest period of time in which a student could complete a standalone certificate nursing program is at least one year but less than two years, then the maximum monitoring period for continuing accreditation for good cause is 18 months from the ACEN Board of Commissioners’ determination of this accreditation status. If compliance with all the Accreditation Standards is not demonstrated within 18 months, the ACEN Board of Commissioners must deny continuing accreditation and remove the nursing program from the list of accredited programs.
    3. If the shortest period of time in which a student could complete a standalone certificate nursing program is at least two years, then the maximum monitoring period for continuing accreditation for good cause is two years from the ACEN Board of Commissioners’ determination of this accreditation status. If compliance with all the Accreditation Standards is not demonstrated within two years, the ACEN Board of Commissioners must deny continuing accreditation and remove the nursing program from the list of accredited programs.

Good Cause

  1. The ACEN Board of Commissioners can extend a nursing program’s continuing accreditation for good cause if the ACEN Board of Commissioners determines the program satisfies all of the following principles:
    1. The nursing program has demonstrated significant recent accomplishments in addressing non-compliance;
    2. The nursing program has documented that it has the potential to remedy all deficiencies within the extended period as defined by the Commission; that is, that the program provides evidence which makes it reasonable for the ACEN Board of Commissioners to determine it will remedy all deficiencies within the extended time defined by the Commission;
    3. The nursing program provides assurance to the ACEN Board of Commissioners that it is not aware of any other reasons, other than those identified by the Commission, why the accreditation of the nursing program could not be continued for good cause.
  1. The nursing program has the responsibility for making its case for good cause. To demonstrate good cause, the Chief Executive Officer of the governing organization and the nurse administrator of the nursing program must submit a report attesting that the program satisfies all three principles for good cause. The report must be received by the ACEN Chief Executive Officer no later than 14 calendar days before the ACEN Board of Commissioners’ meeting. Along with the Good Cause Report, the nursing program may submit selected new, updated information and evidence (e.g., faculty profile table, verification of faculty credentials, and performance on licensure examination) to demonstrate that the program has made significant recent accomplishments in addressing the Standard(s) with which the program was found to be in non-compliance.

FINAL ACCREDITATION DECISION

  1. The ACEN Board of Commissioners’ decision is the final accreditation decision if the governing organization/nursing program does not appeal the denial of initial or continuing accreditation. The effective end date of the nursing program’s accreditation is the end date per the Board of Commissioners’ decision letter.
  1. If the governing organization/nursing program does appeal, the ACEN Board of Commissioners’ decision is the final accreditation decision if the governing organization/nursing program withdraws its appeal before the Appeal Committee renders its decision. The effective end date of the nursing program’s accreditation is the original effective end date per the Board of Commissioners’ decision letter.
  1. If the governing organization/nursing program does appeal, the decision of the Appeal Committee is the final accreditation decision if that decision is to affirm or amend the Board of Commissioners decision. If the result of an appeal is to affirm the ACEN Board of Commissioners’ decision, the original effective end date of the nursing program’s accreditation is also affirmed, which is the original effective end date per the Board of Commissioners’ decision letter.
  1. If the governing organization/nursing program does appeal and the Appeal Committee’s decision is to remand, then acting in a manner consistent with the Appeal Committee’s decision to remand or instructions, the Board of Commissioners will make a second accreditation decision. The second accreditation decision is final. If the second accreditation decision is denial of continuing accreditation, then the original effective end date of the nursing program’s accreditation is the original effective end date per the Board of Commissioners’ decision letter.
  1. If the governing organization/nursing program pursues arbitration, the Appeal Committee’s decision is the final accreditation decision if the governing organization/nursing program withdraws from arbitration before the arbitrators render their recommendation, or if either party to the arbitration notifies the other in writing by 5 p.m. Eastern Standard Time ten calendar days from delivery of the recommendation that they reject it. The effective end date of the nursing program’s accreditation is the original effective end date per the Board of Commissioners’ decision letter.
  1. The ACEN Board of Commissioners’ decision is the final accreditation decision if the governing organization/nursing program fails to meet any deadline in the appeal process or arbitration process. The effective end date of the nursing program’s accreditation is the original effective end date per the Board of Commissioners’ decision letter.

Within one business day of sending written notification, the final accreditation decision will be posted on ACEN website.

Within 60 calendar days of a final accreditation decision to deny initial accreditation or deny continuing accreditation, the ACEN will make available to the Secretary of Education, U.S. Department of Education, the nurse administrator of the program, the Chief Executive Officer of the governing organization, the appropriate state regulatory agency for nursing, the governing organization’s accrediting agency, and the public a brief statement summarizing the reasons for the decision and the official comments that the affected governing organization/nursing program may wish to make with regard to the decision, if any, or the ACEN will provide evidence that the affected institution was offered the opportunity to provide official comment.

Policy #4 History
Revised July 2015
Revised July 2017
Revised October 2017
Revised July 2018
Revised November 2018
Edited June 2020
Revised July 2022

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