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U.S. Department of Education

Staff Report
to the
Senior Department Official
on
Recognition Compliance Issues

RECOMMENDATION PAGE

1.
Agency:   Accreditation Council for Pharmacy Education (1952/2006)
                  (The dates provided are the date of initial listing as a recognized agency and the date of the agency’s last grant of recognition.)
 
2.
Action Item:   Petition for Continued Recognition
 
3.
Current Scope of Recognition:   The accreditation and preaccreditation, within the United States, of professional degree programs in pharmacy leading to the degree of Doctor of Pharmacy, including those programs offered via distance education.
 
4.
Requested Scope of Recognition:   Same.
 
5.
Date of Advisory Committee Meeting:   June, 2012
 
6.
Staff Recommendation:   Continue the agency's recognition and require the agency to come into compliance within 12 months, and submit a compliance report that demonstrates the agency's compliance with the issues identified below.
 
7.
Issues or Problems:   The following issues are discussed in the SUMMARY OF FINDINGS section:

-- The agency needs to require that anyone selected to serve on an appeals panel must first have current training in the agency’s policies and procedures, including those related to distance education.
[§602.15(a)(2)]

-- The agency needs to ensure that a site visit team will be informed regarding the school’s record of student complaints, and not just the unresolved open complaints. [§602.16(a)(1)(ix)]

-- The agency needs to ensure that its public identification of unaccredited programs, both candidates and precandidates, clearly distinguishes them from accredited programs. [§602.16(a)(2)]

-- The agency needs to clarify its written notification policy on final adverse decisions to require that the Secretary, and the appropriate accrediting and state agencies, must be notified at the same time that the school is notified. [§602.26(b)]

-- The agency needs to explain and document the steps that it has taken to ensure that within 60 days of making a final adverse decision, a brief statement will be made available that includes the reasons for the decision, together with any official comments the school made, or evidence the school was offered the opportunity to comment. [§602.26(d)]

-- The agency needs to adopt specific and clear policies and procedures to notify the Secretary, and the appropriate accrediting and state agencies, within 30 days, if a school voluntarily withdraws from accreditation or preaccreditation, or lets either status lapse. The agency also needs to adopt similar policies and procedures to notify the public, upon request. Furthermore, the agency will need to provide evidence that it has implemented these policies, or to attest that it has not had occasion to do so.
[§602.26(e)]

-- The agency needs to amend its policy to clearly prohibit the grant of initial or renewed preaccreditation to an institution’s program, when the institution is subject to a negative action by another body. [§602.28(b)]

-- The agency needs to amend its policy to clearly require the Accreditation Council to review the significance of all the specified adverse actions by other accrediting agencies that may impact any accreditation status or any preaccreditation status granted. [§602.28(d)]

-- The agency needs to amend its information sharing policy to clearly include information about the preaccreditation status of a program and any adverse actions it has taken against a preaccredited program. The agency must also provide documentation to verify implementation of its information-sharing policy, or indicate that it has not had the opportunity to do so. [§602.28(e)]

EXECUTIVE SUMMARY

 
 

PART I: GENERAL INFORMATION ABOUT THE AGENCY

 
The Accreditation Council for Pharmacy Education (ACPE) accredits and preaccredits professional degree programs in pharmacy leading to the Doctor of Pharmacy degree. Currently, the agency accredits approximately 103 programs, and preaccredits 22 programs, throughout the United States, Puerto Rico and the District of Columbia. Those programs are within institutions that are accredited by regional and national accrediting agencies recognized by the Secretary of Education. Since ACPE is not an institutional accreditor, and does not serve as a gatekeeper of Title IV funds, the agency is not required to meet the Secretary’s separate and independent requirements.
 
 
Recognition History
 
The agency was on the first list of nationally recognized accrediting agencies published in 1952. Since that time, the Secretary has periodically reviewed the agency and granted continued recognition. Originally known as the American Council on Pharmaceutical Education, the agency was renamed the Accreditation Council on Pharmacy Education (ACPE) in 2003.

The last full review of ACPE took place at June 2006 meeting of the National Advisory Committee on Institutional Quality and Integrity (NACIQI). After that review the Secretary renewed the agency’s recognition for five years.

As part of its review of the agency’s request for continued recognition, Department staff reviewed the agency’s petition and supporting documentation, and observed an onsite visit conducted by the agency at Fairleigh Dickinson University’s School of Pharmacy in Madison, New Jersey on May 7-9, 2012.

PART II: SUMMARY OF FINDINGS

 
§602.15 Administrative and fiscal responsibilities
The agency must have the administrative and fiscal capability to carry out its accreditation activities in light of its requested scope of recognition. The agency meets this requirement if the agency demonstrates that--

(a) The agency has--
(2) Competent and knowledgeable individuals, qualified by education and experience in their own right and trained by the agency on their responsibilities, as appropriate for their roles, regarding the agency's standards, policies, and procedures, to conduct its on-site evaluations, apply or establish its policies, and make its accrediting and preaccrediting decisions, including, if applicable to the agency's scope, their responsibilities regarding distance education and correspondence education;
 
Board of Directors: The board of directors is both the policy- and decision-making body of the agency. The 10-member board is appointed by three pharmacy organizations representing pharmacy educators, practitioners, and regulators, and by the American Council on Education. The agency's board appointment criteria (found in the agency's bylaws) specifically define the qualifications for board members, thus ensuring that it includes educators, practitioners, and public members. The agency provided the current board roster to demonstrate that its members met the qualifications.

The agency demonstrated that it provides training to board members regarding their role and responsibilities, as well as the standards, policies, and procedures of the agency. As indicated in the narrative and documentation, this training is accomplished through an orientation program, audit attendance at two board meetings, attendance at a site visitor training workshop, optional observation of on-site evaluation, and on-going training. However, the agency has not demonstrated that its board members are specifically trained on their responsibilities regarding programs offered via distance education.

Appeals panel members: The agency provided its appeals policies and procedures, to include the qualifications and selection process for appeals panel members. However, the agency states in the narrative that the appeals panel members will be selected from a list of individuals who have taken the site visitor training workshop, which differs from the selection process stated in the agency's written policy. Therefore, the selection process for appeals panel members is not clear. The agency also did not provide the roster of appeals panel members and therefore, has not demonstrated that they meet the agency's qualifications requirements.

The agency stated that attendance at a site visitor training workshop was a requirement for participation on the appeals panel in order to provide training regarding the standards, policies, and procedures of the agency. If an individual selected to serve on the appeals panel had not completed that workshop, the agency would provide that specific training.

Site visitors: The agency states that an on-site evaluation team includes educators and practitioners, however the agency did not provide its definition or qualification(s) for those roles, nor a mechanism to ensure that site visitors meet those definitions. Although the agency provided a list of site visitor workshop attendees, that list does not demonstrate that the individuals listed met the agency's qualifications requirements for their roles as site visitors.

The agency demonstrated that it provides comprehensive and ongoing training to site visitors regarding their role and responsibilities, as well as the standards, policies, and procedures of the agency. This training is accomplished through attendance at a site visitor training workshop and on-going participation in web-based workshops. First-time site visitors receive further training and mentoring to fulfill their role.

With regards to distance education, the agency did not provide evidence of distance education expertise nor of what qualifications are required to be a distance education site visitor for the agency. The agency also has not demonstrated that its site visitors are specifically trained on their responsibilities regarding programs offered via distance education.

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to demonstrate that its board members and site visitors are qualified and trained on their responsibilities regarding distance education programs. The agency must also demonstrate that appeals panel members are qualified, as required by this section.

Analyst Remarks to Response:
The draft staff analysis found that the agency needs to demonstrate that its board members, and site visitors, are qualified, and trained, on their responsibilities regarding distance education programs. In addition, the agency needs to clarify the selection process for its appeals panel members and to demonstrate that they are qualified, and trained, as well.

In response, the agency reaffirmed that the same training workshops are attended by all site team members, board members, and staff members prior to their service. In addition, the agency acknowledged that its distance education training was not sufficiently addressed in its prior submission. To remedy that oversight, the agency highlighted the fact that the sample self-study used in the training does require training in distance education evaluation techniques. As well, the agency reaffirmed that a staff member or agency consultant who has been specifically trained in the evaluation of distance education is included on all teams, as appropriate.

Regarding evaluation team member qualifications, the agency has clarified that a person cannot even attend the training if they have not held an academic appointment in a pharmacy program or have been a practicing pharmacist for a minimum of five years. In addition, the agency clarified its requirements to serve as a practitioner member, that is, (1) be employed as a practicing pharmacist with no part of their employment affiliated with a college or school of pharmacy; (2) serve as an experiential director at an accredited college or school of pharmacy; or (3) be employed by a national or state pharmacy organization such as a State Board of Pharmacy.

Regarding appeals panel members, the agency affirmed that it has not had occasion to convene an appeals panel, and the agency cited its policy on who will be on an appeals panel should one be convened. In addition, the response narrative states that appeals panel members “may” be selected from the list of trained evaluators. However, the written policy cited by the agency (Exhibit 192 Section 14.2) does not require, or even mention, that appeals panel members must undergo any current training. As well, the written policy makes eligibility for some appeals panel members contingent upon their holding a current office in a pharmacy organization, or on their previous service on the ACPE Board. In both cases there is no requirement that those appeals panel members will have been trained in the agency’s current policies and procedures, including those regarding distance education.

Until, the agency addresses these matters, a finding of compliance cannot be made.

Staff Determination:
The agency does not comply with the requirements of this section. The agency needs to require that anyone selected to serve on an appeals panel must first have current training in the agency’s policies and procedures, including those related to distance education.
 
§602.16 Accreditation and preaccreditation standards
(a) The agency must demonstrate that it has standards for accreditation, and preaccreditation, if offered, that are sufficiently rigorous to ensure that the agency is a reliable authority regarding the quality of the education or training provided by the institutions or programs it accredits. The agency meets this requirement if -
    (1) The agency's accreditation standards effectively address the quality of the institution or program in the following areas:
(a)(1)(ix) Record of student complaints received by, or available to, the agency.
 
The agency’s standards expect that the record of student complaints received by the program will be reviewed as a component of the on-site evaluation process. The record should include the nature of each complaint, the process used to review the complaint, and the resolution of the complaint. Furthermore, the agency specifies its own process for reviewing the complaints that it has received, which covers the steps used to receive, evaluate, and follow-up on any complaints in a consistent manner.

The evidence shows that the agency’s visiting team reviews any record of student complaints received by the program relative to compliance with the agency’s standards, including the resolution of each complaint. However, it appears that the team is not provided with any record of student complaints received by ACPE, at least any record since the last on-site review. Consequently, the full record does not appear to become part of the agency’s accreditation or preaccreditation review of the program. Until this matter is addressed, a finding of compliance cannot be made.

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to make any record of student complaints received by ACPE available to the on-site visiting team.

Analyst Remarks to Response:
The draft staff analysis found that the agency needs to make any record of student complaints received by ACPE available to the on-site visiting team. Specifically, the draft found it unclear if the team was provided with any record of student complaints received by ACPE since the last on-site review.

In response, the agency provided documentation that the agency’s staff member who attends the on-site visit will be aware of the school’s complaint record, however, the team members will only be necessarily informed regarding any open complaints. Since a complaint may be closed anytime in the several years before the team arrives on-site, there is no obligation on the part of the agency to share the complete complaint record with the team. Until this matter is addressed, a finding of compliance cannot be made.

Staff Determination:
The agency does not comply with the requirements of this section. The agency needs to ensure that a site visit team will be informed regarding the school’s record of student complaints, and not just the unresolved open complaints.
 
(a)(2) The agency's preaccreditation standards, if offered, are appropriately related to the agency's accreditation standards and do not permit the institution or program to hold preaccreditation status for more than five years.
 
The agency offers two statuses prior to full accreditation. "Precandidate status" is available for programs that have not yet enrolled students, and "candidate status" is available for programs that have enrolled students, but have not yet graduated a class. In both cases, the agency conducts site visits and uses its accreditation standards to evaluate preaccredited programs, with the understanding that the "evaluation of compliance with standards is based on expectations for a given stage of development." The agency's publicly-available policies indicate that preaccreditation status (the combination of Precandidate and Candidate status) can last a maximum of five years.

Department staff notes two issues with regard to the agency’s presentations regarding preaccreditation. First, under the petition narrative for section §602.19(b), the agency states that “Programs granted preaccreditation status are monitored frequently, generally on-site (five times in the first seven years), throughout the preaccreditation period to assure development and to facilitate movement to the next stage.” This statement, however, appears to conflict with the agency’s published policy that preaccreditation status can last a maximum of five years. A clarification from the agency is needed.

In addition, the agency’s written materials do not consistently make it clear that a program holding a preaccreditation status is not accredited, and that preaccreditation is not an accreditation status. In fact, the agency’s materials appear to conflict with themselves, even in the same paragraph. For example, under its description of “precandidate status,” ACPE states that a new program may be granted “precandidate accreditation status.” The ACPE description also states that “granting of precandidate status brings no rights or privileges of accreditation.”

Furthermore, the agency lists all of its programs, both the unaccredited candidates/precandidates and the accredited programs, together under the same category entitled “Accredited Programs.” Until the agency addresses these matters, a finding of compliance cannot be made.

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to be consistently clear in its published materials that preaccredited programs are not in an accreditation status. In addition, the agency needs to be consistently clear in its published materials that a program cannot remain in a preaccredited status (the combination of Precandidate and Candidate status) for more than five years total.


Analyst Remarks to Response:
The draft staff analysis found that the agency needs to be consistently clear in its published materials that a program cannot remain in a preaccredited status (the combination of Precandidate and Candidate status) for more than five years total. In addition, the agency needs to be consistently clear in its published materials that preaccredited programs are not in an accreditation status. The main concern is that the agency lists all of its programs, both the unaccredited candidates/precandidates and the accredited programs, together under the same category entitled “Accredited Programs.”

In response to the first concern, the agency recognized that its statement in the original submission was unintentionally misleading. Its intent was to note that newly accredited programs are followed especially closely for the first two years after their preaccreditation status has ended. Furthermore, the agency presented evidence that it adheres to its five-year maximum period of preaccreditation.

The agency did not respond to the second concern regarding its publicly available information, in particular, the agency’s listing of all its programs, both the unaccredited candidates/precandidates and the accredited programs, together under the same category entitled “Accredited Programs.” Until this matter is satisfactorily addressed, a finding of compliance cannot be made.

Staff Determination:
The agency does not comply with the requirements of this section. The agency needs to
ensure that its public identification of unaccredited programs, both candidates and precandidates, clearly distinguishes them from accredited programs.
 
§602.26 Notification of accrediting decisions
The agency must demonstrate that it has established and follows written procedures requiring it to provide written notice of its accrediting decisions to the Secretary, the appropriate State licensing or authorizing agency, the appropriate accrediting agencies, and the public. The agency meets this requirement if the agency, following its written procedures--
(b) Provides written notice of the following types of decisions to the Secretary, the appropriate State licensing or authorizing agency, and the appropriate accrediting agencies at the same time it notifies the institution or program of the decision, but no later than 30 days after it reaches the decision:
(1) A final decision to place an institution or program on probation or an equivalent status.

(2) A final decision to deny, withdraw, suspend, revoke, or terminate the accreditation or preaccreditation of an institution or program;

(3) A final decision to take any other adverse action, as defined by the agency, not listed in paragraph (b)(2) of this section;
 
The agency's policies and procedures (in this section and Section 602.26(c)) require the agency to provide written notice to the Secretary, appropriate state regulatory authority, appropriate institutional accrediting agency, and the public at the same time as the program, but no later than 30 days after the adverse action or decision to place a program on probation.

Although the agency provided documentation in Section 602.26(a) of notification of its accreditation actions no later than 30 days after the decision was made to the entities required by this section, the example provided does not demonstrate the notification of negative decisions, nor that the notification occurs at the same time as the program.

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to demonstrate that it provides written notice of negative accreditation decisions to the entities listed in this section at the same time as the program.

Analyst Remarks to Response:
The draft staff analysis found that the agency needs to demonstrate that it provides written notice of negative accreditation decisions to the entities listed in this section at the same time as the program.

In response, the agency noted that the evidence to document its notification of final adverse actions was inadvertently omitted from the original petition. Therefore, the agency submitted a copy of the memorandum it sent to the entities required by this section regarding a final adverse action that the school did not appeal.

However, two issues have become apparent. First, the agency’s policy on adverse notifications does not specifically state that the Secretary, and the appropriate accrediting and state agencies, must be notified at the same time that the school is notified. The policy only requires that these notifications be made within thirty days.

Second, the sample memorandum in Exhibit 171 was actually sent one day before the school was copied. Although this sample represents a circumstance where the appeal period had expired, the agency should ensure that the specified final adverse decision notices are sent at the same time the school is notified, as required by the Secretary, both to document consistent practice and to avoid errors that may invite litigation.

Until the agency’s written notification policy on final adverse decisions is clarified, a finding of compliance cannot be made.

Staff Determination:
The agency does not comply with the requirements of this section. The agency needs to clarify its written notification policy on final adverse decisions to require that the Secretary, and the appropriate accrediting and state agencies, must be notified at the same time that the school is notified.
 
((d) For any decision listed in paragraph (b)(2) of this section, makes available to the Secretary, the appropriate State licensing or authorizing agency, and the public, no later than 60 days after the decision, a brief statement summarizing the reasons for the agency's decision and the official comments that the affected institu­tion or program may wish to make with regard to that decision, or evidence that the affected institution has been offered the opportunity to provide official comment; and
 
The agency's policies and procedures regarding the rationale of negative accreditation decisions meet the requirements of this section. The example provided demonstrates that the agency informs a program that it may submit official comments with regard to the negative decision, and that the agency provides those comments and a brief statement summarizing the reasons for its decision to the Department and the appropriate State licensing or authorizing authority. However, the example provided did not demonstrate that those comments and the brief statement are provided within 60 days of the adverse action.

In addition, Department staff could not verify that the brief statement, as required by this section, is available on the agency's website to meet the notification requirements for the public.

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to provide evidence that it provides its brief statement summarizing the reasons for its adverse action and the official comments of the program within 60 days of the action. The agency must also provide documentation that the statement and comments are available to the public.

Analyst Remarks to Response:
The draft staff analysis found that the agency needs to provide evidence that it provides its brief statement summarizing the reasons for its adverse action and the official comments of the program within 60 days of the action. The agency must also provide documentation that the statement and comments are available to the public. In particular, Department staff could not verify that the brief statement, as required by this section, is available on the agency's website to meet the notification requirements for the public.

In response, the agency recognized that it did not post the required information, but did state that it has taken steps to ensure that this oversight will not be repeated. However, the agency presented no explanation and no documentation of the changes that it has instituted to ensure that it will meet the requirements of this section in the future. Until it does so, a finding of compliance cannot be made.

Staff Determination:
The agency does not meet the requirements of this section. The agency needs to explain and document the steps that it has taken to ensure that within 60 days of making a final adverse decision, a brief statement will be made available that includes the reasons for the decision, together with any official comments the school made, or evidence the school was offered the opportunity to comment.
 
(e) Notifies the Secretary, the appropriate State licensing or authorizing agency, the appropriate accrediting agencies, and, upon request, the public if an accredited or preaccredited institution or program--

(1) Decides to withdraw voluntarily from accreditation or preaccreditation, within 30 days of receiving notification from the institution or program that it is withdrawing voluntarily from accreditation or preaccreditation; or

(2) Lets its accreditation or preaccreditation lapse, within 30 days of the date on which accreditation or preaccreditation lapses.
 
The agency does not have specific and clear policies and procedures regarding written notice to the Department, appropriate state regulatory authority, appropriate institutional accrediting agency, and the public no later than 30 days after a lapse of accreditation or preaccreditation or withdrawal of accreditation or preaccreditation by a program. Although the agency stated in the narrative that it would follow its notification policy concerning adverse actions for these situations, the policies do not require those types of notification.

The agency also did not provide any documentation to demonstrate that it notifies the entities required by this section of voluntary withdrawals of accreditation or accreditation lapses, and did not indicate that it has not had the opportunity to so.

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to demonstrate that it has a policy to meet the notification of voluntary withdrawal and accreditation lapses requirements of this section. The agency must also provide documentation to verify implementation of its notification policy, or indicate that it has not had the opportunity to do so.

Analyst Remarks to Response:
The draft staff analysis found that the agency did not have specific and clear policies and procedures to notify the Secretary, and the appropriate accrediting and state agencies, within 30 days, if a school voluntarily withdraws from accreditation or preaccreditation, or else lets its status lapse. The agency also needed a similar policy to notify the public, upon request.

In response, the agency did not cite any written policy, but did state that it distributes a Report of Proceedings following its decision meetings. The agency’s response included a 12-page sample (Exhibit 217) that included a notice regarding a program that voluntarily relinquished its accreditation on an unspecified date. That notice was included at the end of a list entitled “For Purposes of Considering Continued Accreditation Status.” The agency’s response did recognize that a separate notification may be required, and if so, the agency would implement one in the future.

The Secretary, etc. would have to specifically search the agency’s report very carefully to find the notification. Therefore, an appropriate written policy must be adopted, and implemented, to meet the requirements of this section.

Staff Determination:
The agency does not meet the requirements of this section. The agency needs to adopt specific and clear policies and procedures to notify the Secretary, and the appropriate accrediting and state agencies, within 30 days, if a school voluntarily withdraws from accreditation or preaccreditation, or lets either status lapse. The agency also needs to adopt similar policies and procedures to notify the public, upon request. Furthermore, the agency will need to provide evidence that it has implemented these policies, or to attest that it has not had occasion to do so.

 
§602.28 Regard for decisions of States and other accrediting agencies.
(b) Except as provided in paragraph (c) of this section, the agency may not grant initial or renewed accreditation or preaccreditation to an institution, or a program offered by an institution, if the agency knows, or has reasonable cause to know, that the institution is the subject of--

(1) A pending or final action brought by a State agency to suspend, revoke, withdraw, or terminate the institution's legal authority to provide postsecondary education in the State;

(2) A decision by a recognized agency to deny accreditation or preaccreditation;

(3) A pending or final action brought by a recognized accrediting agency to suspend, revoke, withdraw, or terminate the institution's accreditation or preaccreditation; or

(4) Probation or an equivalent status imposed by a recognized agency.
 
The agency provided its policy that requires State authorization of the institution that sponsors the pharmacy program, and provided documentation of that requirement. The agency also provided its policy regarding its review of programs whose parent institution are subject to an adverse action and the requirement to provide an explanation of the agency's rationale for an over-riding accreditation decision. However, the agency's policies do not clearly state that the agency is prohibited from granting initial or renewed accreditation or preaccreditation to a program that is subject to a negative action by another body.

As stated in Section 602.28(c), the agency has not encountered a situation described by this section and therefore could not provide documentation to verify implementation of its policies and procedures

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to amend its policy to clearly prohibit the grant of initial or renewed accreditation or preaccreditation to a program that is subject to a negative action by another body as required by this section.

Analyst Remarks to Response:
The draft staff analysis found that the agency needs to amend its policy to clearly prohibit the grant of initial or renewed accreditation or preaccreditation to a program that is subject to a negative action by another body as required by this section.

In response, the agency revised its policy on eligibility for accreditation to include language indicating that ACPE is prohibited from granting initial or continued accreditation to a program offered by an institution that is subject to a negative action by another body. However, the agency failed to include eligibility for initial or renewed preaccreditation in the new policy, as specified in the draft analysis. Until it does so, a finding of compliance cannot be made.

Staff Determination:
The agency does not meet the requirements of this section. The agency needs to amend its policy to clearly prohibit the grant of initial or renewed preaccreditation to an institution’s program, when the institution is subject to a negative action by another body.
 
(d) If the agency learns that an institution it accredits or preaccredits, or an institution that offers a program it accredits or preaccredits, 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 agency must promptly review its accreditation or preaccreditation of the institution or program to determine if it should also take adverse action or place the institution or program on probation or show cause.
 
The agency's policy requires it to initiate a review of a program when the agency learns that the program's sponsoring institution is subject to an adverse action by another body, as listed in this section.

Although the agency provided documentation of policy implementation, the documentation was not complete. Specifically, the agency provided the inquiry letter to a program and the program's response, but it did not provide any documentation that the response was forwarded to the Board for review and action.

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to provide complete documentation of policy implementation, to include review and action by the Board.

Analyst Remarks to Response:
The draft staff analysis found that the agency needs to provide complete documentation of policy implementation, to include review and action by the Board.

In response, the agency the revised its current policy to ensure that an adverse action by either an institutional accrediting agency, or a programmatic accrediting agency, that may relate to an ACPE accreditation status will be reviewed by staff. (The policy did not mention preaccreditation status.) If the staff decides there is a problem, then they will forward the materials on to the Accreditation Council for review.

Significantly, the revised policy does not reflect the fact that the Secretary recognizes the Accreditation Council as the decision-makers. Therefore, the relevant policy must require the Accreditation Council to review the significance of all the specified negative actions, and not just agency staff. In addition, the agency’s policy needs to specifically cover negative actions that may impact not just accreditation status, but any preaccreditation status granted by the Accreditation Council, as well. Until these issues are satisfactorily addressed, a finding of compliance cannot be made.

Staff Determination:
The agency does not meet the requirements of this section. The agency needs to amend its policy to clearly require the Accreditation Council to review the significance of all the specified adverse actions by other accrediting agencies that may impact any accreditation status or any preaccreditation status granted.
 
(e) The agency must, upon request, share with other appropriate recognized accrediting agencies and recognized State approval agencies information about the accreditation or preaccreditation status of an institution or program and any adverse actions it has taken against an accredited or preaccredited institution or program.
 
The agency's policies do not meet the information-sharing with appropriate recognized accrediting agencies and recognized State approval agencies requirements of this section. Although the agency states that it shares information through public documents and special notices, the agency does not state that it will, upon request, share with other appropriate recognized accrediting agencies and recognized State approval agencies information about the accreditation or preaccreditation status of a program and any adverse actions it has taken against an accredited or preaccredited program.

The agency also did not provide any documentation to demonstrate that it shares information with other appropriate recognized accrediting agencies and recognized State approval agencies, and did not indicate that it has not had the opportunity to so.

Staff Determination:
The agency does not meet the requirements of this section of the criteria. The agency needs to demonstrate that it has a policy to meet the information-sharing requirements of this section. The agency must also provide documentation to verify implementation of its information-sharing policy, or indicate that it has not had the opportunity to do so.

Analyst Remarks to Response:
The draft staff analysis found that the agency needs to demonstrate that it has a policy to meet the information-sharing requirements of this section. The agency must also provide documentation to verify implementation of its information-sharing policy, or indicate that it has not had the opportunity to do so.

Specifically, the draft found that the agency’s policies did not state that it will, upon request, share with other appropriate recognized accrediting agencies and recognized State approval agencies information about the accreditation or preaccreditation status of a program and any adverse actions it has taken against an accredited or preaccredited program.

In response, the agency revised its policy on information sharing to indicate that it will share the required information, upon request, regarding the status of any program it accredits in conformance with ACPE policies. In addition, the agency included a copy of its general information distribution list. However, the agency failed to include preaccreditation status in the new policy, as specified in the draft analysis. Until it does so, a finding of compliance cannot be made.

Staff Determination:
The agency does not meet the requirements of this section. The agency needs to amend its information sharing policy to clearly include information about the preaccreditation status of a program and any adverse actions it has taken against a preaccredited program.
 
 

PART III: THIRD PARTY COMMENTS

 
The Department did not receive any written third-party comments regarding this agency.