ACEN Substantive Changes – April 2023

Notification of Substantive Change Actions
April 2023

Board of Commissioners Actions

The following publicly available information is provided by the Accreditation Commission for Education in Nursing (ACEN) concerning actions taken on April 7, 2023, by the ACEN Board of Commissioners related to substantive changes. Commission staff will not speculate on what decision might be made by the ACEN Board of Commissioners the next time a program is reviewed. For additional information regarding ACEN accreditation process, access the Accreditation Manual at http://www.acenursing.org/accreditation-manual

Access the ACEN 2017 Standards and Criteria by program type:

The Board of Commissioners approved the substantive change report for the following programs:

  • South Louisiana Community College (Associate) Lafayette, Louisiana, related to the implementation of the New Iberia Campus instructional site.
  • St. Catherine University (Master’s) Saint Paul, Minnesota, related to the implementation of curriculum revisions of 50% or greater.

The Board of Commissioners approved the substantive change report and authorized a focused visit for the following programs:

  • None

The Board of Commissioners approved the substantive change report and requested a written report about the status of the implementation of the substantive change for the following programs:

  • Highland Community College (Associate) Atchison, Kansas, related to a decline in licensure pass rates.

The Board of Commissioners approved the substantive change report and removed the requirement for a focused visit for the following programs:

  • None

The Board of Commissioners denied the substantive change report and authorized a focused visit for the following programs:

  • None

The Board of Commissioners denied the substantive change report for the following programs:

  • None

Definitions

Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with all Accreditation Standards.

Continuing Accreditation with Conditions: A measure imposed by the ACEN Board of Commissioners following the determination of non-compliance with one (1) or two (2) Accreditation Standards. Next review and follow-up action(s) are determined by the Board of Commissioners.

Continuing Accreditation with Warning: A measure imposed by the ACEN Board of Commissioners following the determination of non-compliance with three (3) or more Accreditation Standards. Next review and follow-up action(s) are determined by the Board of Commissioners.

Continuing Accreditation for Good Cause: A measure imposed by the ACEN Board of Commissioners following the determination that a nursing program has not remedied deficiencies at the conclusion of its maximum monitoring period and the program has (a) has demonstrated significant recent accomplishments in addressing ; (b) 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 Commission to determine it will remedy all deficiencies within the extended time defined by the Commission; and (c) provides assurance to the Commission that it is not aware of any other reasons, other than those identified by the Commission, why the nursing program could not be continued for good cause.

Denied Initial Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in non-compliance with one or more Accreditation Standard.

Denied Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program on conditions, warning, or for good cause is found to be in continued non-compliance with any Accreditation Standard. Thereafter the nursing program is removed from the listings of accredited programs.

Focused Visit: A site visit authorized by the ACEN Board of Commissioners to review significant accreditation-related information disclosed about a program as a result of:

A substantive change;

Information revealed about a program between periods of scheduled review;

Information received from the governing organization’s accrediting body related to an adverse action;

Information received from the program’s state regulatory agency for nursing related to a change in its status;

Information revealed by a program during the Evaluation Review Panel process;

Information received from the U.S. Department of Education regarding a program’s compliance responsibilities under Title IV of the Higher Education Act such as information related to a 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.

Follow-up Report: A report prepared by a program addressing the Standard(s) for which the nursing program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.

Initial Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with all Accreditation Standards.

Remove the Conditions Status and Grant Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standard(s) that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.

Remove the for Good Cause Status and Grant Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standards that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.

Remove the Warning Status and Grant Continuing Accreditation: A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standard(s) that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.

Standard:
See ACEN 2017 Standards and Criteria
Clinical Doctorate/DNP Specialist Certificate
Master’s/Post-Master’s Certificate
Baccalaureate
Associate
Diploma
Practical
Substantive Change Report: A report submitted by an accredited program informing the ACEN of a significant modification or expansion of the nature and scope of a nursing program and/or nursing education unit.

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