ACEN Substantive Changes – July 2023

Notification of Substantive Change Actions
July 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 July 14, 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:

Access the ACEN 2023 Standards and Criteria:

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

  • Alaska Pacific University (Practical) Anchorage, Alaska, related to the implementation of the Bartlett Hospital, Mat Su Regional Medical Center, Denali Center/Foundation Health Partners off-campus instructional sites, which will occur August 21, 2023.
  • Arkansas Tech University (Baccalaureate) Russellville, Arkansas, related to the implementation of distance education of 50% or greater.
  • Capital Community College (Associate) Hartford, Connecticut, related to the merger of twelve community colleges into one Connecticut State Community College, which occurred July 1, 2023. Capital Community College’s name will change to Connecticut State at Capital Community College.
  • Gateway Community College (Associate) New Haven, Connecticut, related to the merger of twelve community colleges into one Connecticut State Community College, which occurred July 1, 2023. Gateway Community College’s name will change to Connecticut State at Gateway Community College.
  • New England Institute of Technology (Master’s) East Greenwich, Rhode Island, related to the implementation of a new Nurse Educator Post Master’s Certificate program option.
  • Northern Wyoming Community College District (Associate) Gillette, Wyoming, related to a contractual agreement with Gillette Community College District for an off-campus instructional site .
  • Southern Adventist University (Clinical Doctorate) Collegedale, Tennessee, related to the implementation of a new Doctor of Nursing Practice (DNP) program option.
  • SOWELA Technical Community College (Associate) Lake Charles, Louisiana, related to the implementation of the Lamar Salter off-campus instructional site.
  • St. Elizabeth Medical Center (Associate) Utica, New York, related to the merger of Mohawk Valley Health System’s two existing acute care hospitals St. Elizabeth Medical Center (SEMC) and Faxton-St. Luke’s Healthcare (FSLH) into one integrated acute care hospital.

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:

  • Hennepin Technical College (Practical) Brooklyn Park, Minnesota, related to a decline to 2022 licensure pass rates.
  • Wayne County Community College District (Associate) Detroit, Michigan, related to a decline in 2022 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

See ACEN 2023 Standards and Criteria
2023 Accreditation Manual – Section III – 2023 Standards and Criteria

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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