U.S. Department of Education
Staff Report
to the
Senior Department Official
on
Recognition Compliance Issues
| 1. | - Agency: Council on Chiropractic Education, The
(1974/2006)
(The dates provided are the date of initial listing as a recognized agency and the date of the agency’s last grant of recognition.)
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| 2. | - Action Item: Petition for Continued Recognition
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| 3. | - Current Scope of Recognition: The accreditation of programs leading to the Doctor of Chiropractic degree and single-purpose institutions offering the Doctor of Chiropractic program.
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| 4. | - Requested Scope of Recognition: Same as above.
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| 5. | - Date of Advisory Committee Meeting: December, 2011
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| 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.
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| 7. | - Issues or Problems: The agency must demonstrate that it meets the requirements under 602.14(b) regarding its public members. 602.14(a)
The agency must demonstrate an effective mechanism for ensuring that its public member selectees adhere to the Secretary’s definition of a public member. 602.14(b)
The agency must provide information and documentation regarding the qualifications and training of its appeals panel members. 602.15(a)(2)
The agency must provide information and demonstrate its specific use of academicians and administrators on its decision-making bodies, to include appeals panel members. 602.15(a)(3)
The agency must provide information and demonstrate its specific use of educators and practitioners on its decision-making bodies, to include appeals panel members. 602.15(a)(4)
The agency must provide evidence of an effective mechanism to verify that the public members of both its council and its appeals panel adhere to the Department's definition of a public member. 602.15(a)(5)
The agency must provide evidence of the application of its conflict-of-interest policies. Additional information is also needed regarding its policies and evidence applicable to councilors, site team members, agency staff members, and consultants and other representatives (to include appeals panel members). 602.15(a)(6)
The agency must clarify its file management plan regarding records of substantive changes and correspondence related to accrediting decisions to meet the new requirements of this section. 602.15(b)
The agency must provide evidence of the application of its requirements related to the quality of the program in the area of student support services. 602.16(a)(1)(vi)
The agency needs to provide information on how its standards address quality requirements related to recruiting, catalogs, and publications. The agency must also provide evidence of the application of its standards in assessing the quality of the program related to recruiting and other practices. 602.16(a)(1)(vii)
The agency must provide evidence of the review of its standard that the program have grievance policies and demonstrate that it assesses the record of student complaints in its assessment of a program for accreditation. 602.16(a)(1)(ix)
The agency must provide information regarding its review of reports, such as the review protocol, threshold expectations, and/or triggers it has established that raise concern and action by the council. 602.19(b)
The agency must provide information and documentation of its annual collection and review of headcount data. 602.19(c)
The agency must document that it enforces a two-year time limit for its programs/institutions to bring themselves into compliance with the agency's standards. 602.20(a)
The agency must demonstrate that it has policies that specifically address extensions for good cause, as well as criteria that ensure the extensions are only granted in unusual circumstances and under limited timeframes. 602.20(b)
The agency must provide documentation of its approval of various substantive changes. 602.22(a)(1)
The agency must add the required change in objectives to its definitions of substantive change. The agency must also provide documentation of its review of various types of substantive change requests. 602.22(a)(2)(i-vii)
The agency must address the requirements of this criterion to include documentation of its application of the protocol, or it needs to state that it will not allow prior approvals for the establishment of additional locations. 602.22(a)(2)(viii)
The agency must establish an appropriate policy/protocol and demonstrate its effective application of the requirements of this criterion regarding when new evaluations are required. 602.22(a)(3)
The agency must establish appropriate policy/protocol and demonstrate its effective application of the requirements of this criterion to establish and demonstrate effective protocols for approving substantive changes that include specific effective dates that are not retroactive. 602.22(b)
The agency must provide documentation of its implementation of its approval of substantive changes; specifically, how it determines the fiscal and administrative capacity of the institution to operate the additional location. 602.22(c)
The agency must provide additional information and documentation that it conducts site visits to newly established additional locations within the required six month timeframe. 602.22(c)(1)
The agency must provide additional information regarding its sampling requirements for site visiting additional locations at an institution having more than three locations. 602.22(c)(2)
The agency must provide additional narrative addressing the conditions that will require a site visit or what alternative mechanisms it will use to ensure educational quality under the conditions of this criterion. The agency needs to also provide documentation of effective application of mechanisms to address the requirement of this criterion. 602.22(c)(3)
The agency must demonstrate that it makes available to the public the names, academic and professional qualifications, and relevant employment and organizational affiliations of the members of the agency's policy and decision-making bodies; and the agency's principal administrative staff. 602.23(a)
The agency must amend its complaint process to address the concerns described in the analysis of this criterion and provide documentation illustrating its effective review and resolution of complaints under these processes. 602.23(c)
The agency must amend its policies to require a site visit within six months to institutions that have undergone a change in ownership and provide evidence of its conduct of a site visit after a change in ownership. 602.24(b)
The agency must establish policies that require teach-out plans and that include the requirement that an institution submit a teach-out plan on the occurrence of the events listed in the criterion. 602.24(c)(1)
The agency must establish and demonstrate the effective application of its evaluation of teach-out plans that includes agency-established criteria by which it assesses that the proposed teach-out plan provides for equitable treatment of students, specifies additional changes and provides (appropriate ) notification to students of those charges. 602.24(c)(2)
The agency must amend its policies to include the requirement that it will notify other agencies of teach-out plans it has approved,as appropriate, and demonstrate effective application as applicable. 602.24(c)(3)
The agency must develop appropriate guidance and review protocol for receiving and reviewing teach-out agreements that includes an assessment of the teach-out criteria under 602.24(5) (i and ii) and demonstrate its effective review and approval of a teach-out agreement in the context of the criterion. 602.24(c)(5)
The agency needs to provide evidence of its effective application of its policy to work with state and federal agencies to ensure that, in the case of a program closing without a teach-out agreement, students are given opportunities to complete their education without incurring additional charges. 602.24(d)
The agency must amend its requirements related to transfer of credit to include the requirements under §668.43(a)(11) and demonstrate its effective application of this requirement during accreditation reviews. 602.24(e)
The agency must provide evidence that it has and effectively applies policies and procedures for the review and determination of the reliability and accuracy of an institution's credit hour assignments. 602.24(f)(2)
The agency must develop and demonstrate that it effectively applies policies related to credit hour review and their enforcement. 602.24(f)(3)
The agency must develop and effectively apply policies related to credit hour review, enforcement, and notification that include the requirement to notify the Department of any systemic noncompliance with the agency’s credit hour policies on credit hour assignment. 602.24(f)(4)
The agency must demonstrate that its appeals panel members are subject to its conflict-of-interest policy. 602.25(f)
The agency must clarify the obligation of the agency to provide evidence that it has offered the affected institution the opportunity to provide comments. 602.26(d)
The agency must amend its policy regarding the reporting of Title IV fraud and abuse to reflect the confidentiality requirements under 602.27(b). 602.27(a)(6-7),(b)
The agency needs to amend the language of its policy to more closely conform to the requirements of this section. 602.28(b)
The agency must provide evidence of the application of its policy on providing explanations of over-riding decisions. 602.28(c)
The agency must amend its policies to clarify that it will promptly investigate information it receives from any source regarding negative accrediting actions taken by other agencies and provide evidence of its prompt review of a program that is located in an institution that is the subject of an adverse action or pending action or of a CCE-accredited institution that is subject to a pending or final action. 602.28(d)
The agency must amend its policy to clearly state that information regarding accreditation status or adverse accrediting actions will be available to other agencies upon request and demonstrate effective application of the policy. 602.28(e)
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PART I: GENERAL INFORMATION ABOUT THE AGENCY |
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| The Council on Chiropractic Education is recognized as a specialized accreditor. It currently accredits 15 doctor of chiropractic programs at 18 sites in 13 states. Of these programs, CCE accredits one program that is offered through a single-purpose chiropractic institution. The agency's one single-purpose chiropractic institution uses the agency's accreditation to establish eligibility to participate in the Title IV HEA programs. Accreditation by the agency also allows its 15 programs to participate in non-Title IV programs offered through the Department of Health and Human Services (HHS). |
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| Recognition History |
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| CCE was first recognized by the Commissioner of Education in 1974 and has received periodic renewal of recognition since that time. The agency was last reviewed for continued recognition at the Spring 2006 NACIQI meeting. At that time, it received continued recognition for a period of five years and was requested to submit an interim report on items related to four criteria. The agency's subsequent interim report was reviewed and accepted by the NACIQI at its Fall 2007 meeting. |
PART II: SUMMARY OF FINDINGS |
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| §602.14 Purpose and organization |
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(a) The Secretary recognizes only the following four categories of agencies:
The Secretary recognizes...
(1) An accrediting agency
(i) Has a voluntary membership of institutions of higher education;
(ii) Has as a principal purpose the accrediting of institutions of higher education and that accreditation is a required element in enabling those institutions to participate in HEA programs; and
(iii) Satisfies the "separate and independent" requirements in paragraph (b) of this section.
(2) An accrediting agency
(i) Has a voluntary membership; and
(ii) Has as its principal purpose the accrediting of higher education programs, or higher education programs and institutions of higher education, and that accreditation is a required element in enabling those entities to participate in non-HEA Federal programs.
(3) An accrediting agency for purposes of determining eligibility for Title IV, HEA programs--
(i) Either has a voluntary membership of individuals participating in a profession or has as its principal purpose the accrediting of programs within institutions that are accredited by a nationally recognized accrediting agency; and
(ii) Either satisfies the "separate and independent" requirements in paragraph (b) of this section or obtains a waiver of those requirements under paragraphs (d) and (e) of this section.
(4) A State agency
(i) Has as a principal purpose the accrediting of institutions of higher education, higher education programs, or both; and
(ii) The Secretary listed as a nationally recognized accrediting agency on or before October 1, 1991 and has recognized continuously since that date.
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The agency is seeking continued recognition under 602.14(a)(3). The agency has a volunteer membership of 14 programs that participate in programs administered by the HHS, as well as one free-standing institution that uses accreditation by the agency as its link to Title IV programs. The agency's bylaws demonstrate that it is an independent organization whose primary purpose is accreditation. The agency is not affiliated with a parent organization. However, the agency has not yet demonstrated that it meets the requirements under 602.14(b) or the waiver requirements under 602.14(d).
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate that it meets the requirements under 602.14(b) or the waiver requirements under 602.14(d).
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Analyst Remarks to Response: |
In its response to the draft staff analysis, the agency notes this section's connection to the requirements found under 602.14(b), which is also related to the requirements under 602.15(a)(5). As noted under these two additional sections, the agency still needs to provide additional information regarding the qualifications of its public members.
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate that it meets the requirements under 602.14(b) regarding its public members. |
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(b) For purposes of this section, the term separate and independent means that--
(1) The members of the agency's decision-making body--who decide the accreditation or preaccreditation status of institutions or programs, establish the agency's accreditation policies, or both--are not elected or selected by the board or chief executive officer of any related, associated, or affiliated trade association or membership organization;
(2) At least one member of the agency's decision-making body is a representative of the public, and at least one-seventh of that body consists of representatives of the public;
(3) The agency has established and implemented guidelines for each member of the decision-making body to avoid conflicts of interest in making decisions;
(4) The agency's dues are paid separately from any dues paid to any related, associated, or affiliated trade association or membership organization; and
(5) The agency develops and determines its own budget, with no review by or consultation with any other entity or organization.
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As noted previously, the agency is an independent body and is not affiliated with any parent organization, as is documented in its bylaws. The agency's decision-making body members are independent of any other association or organization. Category 1 councilors, who are full-time employees of the member programs, are chosen by a majority vote of the member representatives. The remaining councilors in categories 2, 3, and 4 are elected by a majority vote of all councilors.
The agency's current roster of commissioners demonstrates that it meets the public member percentage requirements. However, more information is needed regarding the public members' qualifications in order to verify that they meet the definition of a public member.
The agency provided its published conflict of interest declaration. It requires information regarding: which of the agency's programs (if any) a person graduated from; whether a person has served as an employee or consultant for one of the agency's programs; whether a person has been a candidate for employment at one of the agency's programs; if a person is a board member at one of the agency's programs; whether a person's family member has any of the above conflicts; whether a person has any other relationship with one of the agency's programs; and if a person has any other circumstances that could be perceived as a conflict of interest regarding one of the agency's accredited programs. The agency provided meeting minutes demonstrating that councilors had recused themselves from discussions of various programs.
The agency's dues are independent of any other association or organization, and the agency develops its own budget. The agency collects fees, dues, and expenses from its member programs, and the members may be suspended or terminated if they do not pay them.
Staff determination: The agency does not meet the requirements of this section. The agency must provide more information regarding the qualifications of its public members. |
Analyst Remarks to Response: |
In its response to the draft staff analysis, the agency refers ED staff to its response under 602.15(a)(5). As noted in the staff analysis under that section, the agency’s evidence that its public members meet the Secretary’s definition of a public member is incomplete. While the agency adheres to good practice by using a conflict-of-interest statement to ensure that the circumstances of public members have not changed, two of the signed statements that were provided left the questions unanswered, with a block checked at the bottom of the statement noting that "My conflicts of interest declarations are current." It is unclear what previous document this refers to and is also unclear why members are not simply required to answer the seven yes/no conflict questions on the form rather than stating that their declarations are current. It should also be noted that the form for the fourth public member was missing altogether. Also, it remains unclear how the agency confirms that public members adhere to the Secretary’s definition prior to selecting/seating its public members. The agency still needs to provide evidence of an effective mechanism to verify that the public members of its council and appeals panel adhere to the Department's definition of a public member.
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate an effective mechanism for ensuring that its public member selectees adhere to the Secretary’s definition of a public member.
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§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--
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(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;
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Council:
The agency supplied a list of 24 current councilors (commissioners), including 11 institutional representatives, eight practitioners, and five public members. The agency's bylaws specify that councilors include people who are active in instruction, research, service, and/or administrative components of chiropractic education or doctors of chiropractic currently in practice. Sample resumes provided by the agency indicate that the councilors are qualified by both education and experience for their role. The agency provided a detailed outline of its new councilor orientation training, which was comprehensive and included general information, information on council processes (meetings, accreditation activities, substantive change requests, complaints, policies, conflict of interest, confidentiality, standards revision, and funding), as well as information on the agency's recognition by ED.
Site Visitors:
The agency provided a list of 57 potential site visitors, which included administrators, educators, and practitioners, listing highest degree attained and professional affiliation. Based upon the information provided, all would appear to be appropriately qualified to serve as site team members. However, no policy information was provided showing that the agency specifies the qualifications of its site visitors. The agency provided detailed agendas from recent site team visitor training sessions, which included presentations on council processes, types of site visits, self-studies, pre-visit activities, site visit activities, post-visit activities, overviews of the agency's manual, preparation for visits, areas of assignment, and practice scenarios. Although the agency's site visitors appear appropriately qualified, documentation regarding the agency's published requirements related to the qualifications of its site visitors is needed.
Appeals Panel:
The qualifications and training of the agency's appeals panel members were not addressed nor documented. More information is needed in this area.
Distance:
Distance/correspondence education is not included in the agency's current scope of recognition, and the agency is not requesting an expansion of scope in this area.
Staff determination: The agency does not meet the requirements of this section. The agency must provide documentation regarding its published requirements related to the qualifications of its site visitors. The agency must provide information and documentation regarding the qualifications and training of its appeals panel members. |
Analyst Remarks to Response: |
Site Visitors:
In its response to the draft staff analysis, the agency referred staff to Policy 10 in its policy manual, which includes a list of qualifications that individuals must have in order to be eligible to serve as site team members. The policy also specifies that the agency's site team academy committee conducts reviews of all active site members at regular intervals to verify that they continue to meet the site visitor eligibility requirements.
Appeals Panel:
In its response to the draft staff analysis, the agency referred staff to Policy 8 in its policy manual. Under a section on "Criteria for selecting an Appeals Panel" the agency specifies that it shall maintain a standing list of individuals "who have a working knowledge of the CCE accreditation process and the CCE Standards for Doctor of Chiropractic Programs and Requirements for Institutional Status" to serve on appeals panels as needed. This is not sufficiently descriptive to ascertain the agency’s expectations regarding the qualifications expected of appeals panel members. No further information regarding appeals panel members was provided. The agency stated in its narrative that it has not developed training for appeals panel members other than providing members with a copy of Policy 8 and a verbal orientation prior to service on a panel.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information and documentation regarding the qualifications and training of its appeals panel members. |
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(3) Academic and administrative personnel on its evaluation, policy, and decision-making bodies, if the agency accredits institutions;
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The agency accredits one free-standing institution, but did not provide a response to this criterion. More information is needed in this area. In providing this information, the agency clearly must clearly demonstrate that it has/includes these types of representatives on its council, site teams, and appeals panels.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information regarding its use of academic and administrative personnel on its evaluation, policy, and decision-making bodies. |
Analyst Remarks to Response: |
In response to the draft staff analysis, the agency provided a list of its councilors and site team members, broken out by category. The agency's list demonstrates that it has several academic/administrator representatives on both its council and on it list of potential site visitors. However, the agency did not address the requirements of this section as they pertain to appeals panel members.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information and demonstrate its specific use of academicians and administrators on its decision-making bodies, to include appeals panel members. |
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(4) Educators and practitioners on its evaluation, policy, and decision-making bodies, if the agency accredits programs or single-purpose institutions that prepare students for a specific profession;
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The agency must provide a more detailed response specific to its compliance with the requirements of this criteria. The agency must clearly demonstrate that it has/includes these types of representatives on its council, site teams, and appeals panel. The agency has not made clear how it defines, and which councilors represent, the category of educator vs. administrator, or that site teams include each of these perspectives on each programmatic team review.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information and demonstrate its specific use of educators and practitioners on its evaluation, policy, and decision-making bodies (to include appeals panels, as appropriate). |
Analyst Remarks to Response: |
In response to the draft staff analysis, the agency provided a list of its councilors and site team members, broken out by category. However, the agency's documentation raises additional questions as to the accuracy of its designations, since some designations do not appear to match with the person's current employer. While the agency has identified categories, it has not provided sufficient evidence to support its designations. And while the agency's list indicates that it has several educator/practitioner representatives on both its council and on its list of potential site visitors, there was not sufficient information provided about them to be certain that they are assigned to the correct category.
The agency did not address the requirements of this section as they pertain to appeals panel members.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information and demonstrate its specific use of educators and practitioners on its decision-making bodies, to include appeals panel members. |
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(5) Representatives of the public on all decision-making bodies; and
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Council:
The agency's bylaws under 6.02(c) specify that at least four of the agency's 24 councilors shall be public members that comply with the definition in the criteria for recognition. The bylaws clearly identify the requirements (i.e., exclusions) relative to the public member position. The current council includes four public members, as required. The four public members, whose resumes were provided, include a university vice president, a regional accrediting agency vice president, the president of a biomedical consulting firm, and an attorney. However, the agency did not provide evidence of an effective mechanism to verify that its public members adhere to the Department’s definition of a public member, specifically components 2 and 3 under the definition.
Appeals Panel:
The agency did not address the requirements of this criterion relative to its appeals panels. More information is needed in this area.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of an effective mechanism to verify that its public members adhere to the Department’s definition of a public member. The agency must also address the inclusion of public members in its appeals panel pool and on its appeals panels.
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Analyst Remarks to Response: |
Council:
In response to the draft staff analysis, the agency provided signed conflict of interest statements for three of its four public members. The forms do address components (2) and (3) under ED's definition of a public member. However, two of the signed statements that were provided left the questions unanswered, with a block checked at the bottom of the statement noting that "My conflicts of interest declarations are current." It is unclear what previous document this refers to and is also unclear why members are not simply required to answer the seven yes/no conflict questions on the form rather than stating that their declarations are current. It should also be noted that the form for the fourth public member was missing altogether. The agency still needs to provide evidence of an effective mechanism to verify that its public members adhere to the Department's definition of a public member.
Also, staff has a concern that, while the selection process is described, it is not clear that the agency has mechanisms in its process to specifically determine that the individuals meet the public member definition prior to their selection. There is no evidence that nominees are queried regarding whether they meet the definition. Identifying that a member does not meet the definition after the member has been selected and seated is not good practice. There is a difference in the purpose and function of the regulations for situational conflicts of interest vs. the category of a “public member,” which disallows involvement in all decision-making and agency functions by a public member who does not meet the public member definition.
Appeals Panel:
The agency is in the process of clarifying its policies to note that appeals panel members are included in the agency's conflict of interest policy. The agency stated that it currently has three public members available for appeals panels; however, no evidence of their meeting the requirements of the definition of a public member was provided.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of an effective mechanism to verify that the public members of both its council and its appeals panel adhere to the Department's definition of a public member.
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(6) Clear and effective controls against conflicts of interest, or the appearance of conflicts of interest, by the agency's--
(i) Board members;
(ii) Commissioners;
(iii) Evaluation team members;
(iv) Consultants;
(v) Administrative staff; and
(vi) Other agency representatives; and
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CCE Policy 18 addresses conflict of interest requirements for councilors, site team members, member representatives, CCE staff, other CCE representatives, and consultants and lists examples of conflicts, such as whether a person is a graduate of a program or institution, has served as a consultant, has been a candidate for employment, etc.
Sample conflict of interest forms were provided as documentation, as well as a list that the office maintains to track which councilors have conflicts with the agency's various programs. However, blank templates do not suffice as evidence of application of the agency's policies. Additional information is also needed regarding policies and evidence applicable to agency staff, appeal panel members, and consultants, as applicable.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of application of its policies. Additional information is also needed regarding policies and evidence applicable to agency staff, appeal panel members, and consultants, as applicable.
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Analyst Remarks to Response: |
Commissioners:
The agency provided signed conflict-of-interest forms for its council members. However, some of the signed statements that were provided left the questions unanswered, with a block checked at the bottom of the statement noting that "My conflicts of interest declarations are current." It is unclear what previous document this refers to and is also unclear why members are not simply required to answer the seven yes/no conflict questions on the form rather than stating that their declarations are current. The agency provided no other evidence of its effective application of mechanisms to guard against conflict of interest. The agency needs to provide evidence of the effective application of its conflict-of-interest policies for council members.
Evaluation team members:
The agency notes that its policy manual addresses conflicts of interest under Policy 18. The policy specifies that evaluation team members are subject to the agency's conflict of interest policies and lists possible conflicts of interest. It also requires site visitors to declare conflicts prior to a site visit. It is unclear how (or if) the site team members do this; no site visitor examples of the agency’s practices with regard to conflict-of-interest were provided as evidentiary documentation.
Agency staff:
As noted previously, the agency's Policy 18 addresses conflict of interest. The policy specifies that agency staff members are subject to the agency's conflict of interest policies. No examples of conflicts for agency staff are provided in the policy manual, so it is unclear how staff members are to know if they have any conflicts. The agency states in its narrative that staff members do not sign conflict of interest forms, although they do sign Guest Confidentiality Agreements when they attend site visits.
Consultants and other representatives:
As noted previously, the agency's Policy 18 addresses Conflict of Interest. The policy specifies that consultants and other CCE representatives are subject to the agency's conflict of interest policies. Again, no examples of conflicts for these groups are listed in the policy manual. The agency states that it has not employed consultants or other representatives (including appeals panel members) during this review cycle, and has no evidence, in accordance with its policies, to provide.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of the application of its conflict-of-interest policies. Additional information is also needed regarding its policies and evidence applicable to councilors, site team members, agency staff members, and consultants and other representatives (to include appeals panel members).
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(b) The agency maintains complete and accurate records of--
(1) Its last full accreditation or preaccreditation reviews of each institution or program, including on-site evaluation team reports, the institution's or program's responses to on-site reports, periodic review reports, any reports of special reviews conducted by the agency between regular reviews, and a copy of the institution's or program's most recent self-study; and
2) All decisions made throughout an institution's or program's affiliation with the agency regarding the accreditation and preaccreditation of any institution or program and substantive changes, including all correspondence that is significantly related to those decisions.
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The agency provided detailed file management plans for the maintenance and disposition of the records addressed in this section. The plans specify that documentation regarding its accredited programs be kept for the current and last full accreditation cycles. Documents related to accreditation actions are permanently maintained electronically. The agency also provided lists demonstrating that it reviews its documents on a regular schedule.
However, it is not clear that records are maintained in accordance with the criterion. It appears that records of substantive changes and correspondence related to accrediting decisions are not kept in accordance with the new requirements of this section.
Staff determination: The agency does not meet the requirements of this section. The agency must modify its file management plan regarding records of substantive changes and correspondence related to accrediting decisions to meet the new requirements of this section. |
Analyst Remarks to Response: |
In its response, the agency referred ED staff to its file management plan, which requires that the agency maintain records of substantive changes and correspondence related to accrediting decisions in accordance with its Rule 11. Rule 11 requires "Maintain one complete accreditation cycle. Cycle ends on the date of status award by the Council/COA, then the new cycle begins."
The agency's Rule 16 states "Do not destroy. Maintain two years in active files, five years in inactive files. Keep for historical purposes. Turn over to proper records custodian if agency secedes or transfers to other authority." It is unclear from the wording of this rule whether files kept under this rule are never destroyed or whether they are destroyed after five years.
ED's new requirements under this section are that such documentation be maintained permanently. The agency must clarify its file plan to reflect the new requirements of this section.
Staff determination: The agency does not meet the requirements of this section. The agency must clarify its file management plan regarding records of substantive changes and correspondence related to accrediting decisions to meet the new requirements of this section. |
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§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:
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(a)(1)(vi) Student support services.
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The agency's Standard F Student Support Services requires that institutions provide services that help students reach their full academic potential. The standard defines student support services as including the following areas:
-registration
-orientation
-academic advising and tutoring
-financial aid counseling
-career placement
-appeals
-grievances and disciplinary matters
However, it was not clear what are the quality indicators the agency uses to assess that the services meet the expectations or where these areas of student support services are assessed in the sample site visit report provided by the agency.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of the application of its requirements related to the quality of the program in the area of student support services. |
Analyst Remarks to Response: |
The agency states that it will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of the application of its requirements related to the quality of the program in the area of student support services. |
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(a)(1)(vii) Recruiting and admissions practices, academic calendars, catalogs, publications, grading, and advertising.
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The agency's Standard B Ethics and Integrity requires that the program demonstrate adherence to standards in a variety of areas, including: admissions, including academic prerequisites and financial aid; the academic calendar, academic standards, and tuition and fees; grading and other forms of student evaluation, grade appeals, withdrawal, and readmission; and advertising and marketing activities.
The agency's standards do not appear to specifically address recruiting, catalogs, or publications. More information is needed in these areas. Moreover, it was not clear where the requirements of this section, other than minimum admissions requirements, were addressed in the sample site review report provided by the agency.
Staff Determination: The agency does not meet the requirements of this section. The agency needs to provide information on how its standards address quality requirements related to recruiting, catalogs, and publications. The agency must also provide evidence of the application of its standards in assessing the quality of the program related to recruiting and other practices.
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Analyst Remarks to Response: |
The agency did not provide the requested information and states that it will address the requirements of this section in its report.
Staff Determination: The agency does not meet the requirements of this section. The agency needs to provide information on how its standards address quality requirements related to recruiting, catalogs, and publications. The agency must also provide evidence of the application of its standards in assessing the quality of the program related to recruiting and other practices.
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(a)(1)(ix) Record of student complaints received by, or available to, the agency.
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Student complaints at the program level are addressed under the agency's Standard F. Student Support Services. The standard requires programs to have policies and procedures to address student complaints and grievances and that hearings and proceedings be documented by related records. However, this standard alone does not establish compliance. This criterion requires that the agency demonstrate that it reviews the "record of student complaints" that are filed against a program in its review of the program for accreditation. The agency would take into consideration whether the complaints against a program establish/identify a systemic problem in any areas under the agency’s standards. Therefore, reviewing only whether the program has a complaint/grievance policy does not get to the heart of the expectation under this requirement.
The agency provided no evidence of the agency's review of its standard that the program have grievance policies. Neither did it demonstrate that it assesses the record of student complaints in its assessment of a program for accreditation.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of the review of its standard that the program have grievance policies and demonstrate that it assesses the record of student complaints in its assessment of a program for accreditation.
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Analyst Remarks to Response: |
The agency states that it will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of the review of its standard that the program have grievance policies and demonstrate that it assesses the record of student complaints in its assessment of a program for accreditation.
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§602.19 Monitoring and reevaluation of accredited institutions and programs. |
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(b) The agency must demonstrate it has, and effectively applies, a set of monitoring and evaluation approaches that enables the agency to identify problems with an institution's or program's continued compliance with agency standards and that takes into account institutional or program strengths and stability. These approaches must include periodic reports, and collection and analysis of key data and indicators, identified by the agency, including, but not limited to, fiscal information and measures of student achievement, consistent with the provisions of §602.16(f). This provision does not require institutions or programs to provide annual reports on each specific accreditation criterion.
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The agency has numerous mechanisms in place to monitor the resolution of issues that include site visits, progress reports, substantive change reports, and program characteristic biennial reports. Its primary means of conducting routine monitoring is through the program characteristics report, which is required of all programs/institutions every two years.
A sample report was provided, which documented that the agency requires information and data on numerous indicators and topical areas to include: student enrollment, completion, national test pass rates, planning, outcomes, clinicals and data research activities. The report contained no information on financials. The agency provided no information or insight into its collection or review of financial information. Additionally, the agency provided no information or evidence regarding its review of these reports such as the review protocol, the threshold expectation, and/or triggers it has established that raise concern and action by the council.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information on its collection of financial information, as well as information regarding its review of reports, such as the review protocol, the threshold expectation, and/or triggers it has established that raise concern and action by the council.
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Analyst Remarks to Response: |
In its response, the agency demonstrated via a sample report that it does require information on financials. The report contained the two most recent years of audited financial statements for the program in question. Since the reports are submitted every two years, this in effect provides the agency with a reasonable and current collection of financial data on which to assess the program against agency standards and expectations. In its response narrative, the agency also provided a description of how a program's/institution's financials are reviewed by the agency and examples of action letters related to financials.
It should also be noted that the requirements of this section refer not only to financial data, but to other key data and indicators required by the agency in its report, including measures of student achievement. It is not clear from the agency's response that it has written procedures for the review of its biannual reports by its staff and council, nor is it clear that such information is provided to programs/institutions. The agency provided no information as to threshold expectations and/or triggers it has established that raise concern and action by the council.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information regarding its review of reports, such as the review protocol, threshold expectations, and/or triggers it has established that raise concern and action by the council.
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(c) Each agency must monitor overall growth of the institutions or programs it accredits and, at least annually, collect headcount enrollment data from those institutions or programs.
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The agency's Program Characteristics report was described under the analysis of 602.19(b). While the agency does collect headcount information in the report, the agency only requires this report to be submitted every two years, not annually. The agency has recently passed policies requiring the annual collection of aggregated enrollment data. The agency must provide more information and evidence of its collection and review of headcount information on an annual basis, as required in this section.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information and documentation of its annual collection and review of headcount data. |
Analyst Remarks to Response: |
The agency is amending its procedures to meet the requirements of this section and will address its progress in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must provide information and documentation of its annual collection and review of headcount data. |
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§602.20 Enforcement of standards |
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(a) If the agency's review of an institution or program under any standard indicates that the institution or program is not in compliance with that standard, the agency must--
(1) Immediately initiate adverse action against the institution or program; or
(2) Require the institution or program to take appropriate action to bring itself into compliance with the agency's standards within a time period that must not exceed--
(i) Twelve months, if the program, or the longest program offered by the institution, is less than one year in length;
(ii) Eighteen months, if the program, or the longest program offered by the institution, is at least one year, but less than two years, in length; or
(iii) Two years, if the program, or the longest program offered by the institution, is at least two years in length.
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The agency does not accredit any programs that are less than two years in length, and the agency's 2007 standards document mirrors the requirements contained in 602.20(a)(2)(iii) of this section. The agency provided a sample letter noting its requirement related to the two-year compliance limitation specified under this section. This is not sufficient to demonstrate the agency’s compliance with this criterion.
However, based on the agency’s procedures outlined in its 2007 and 2012 standards documents it is not clear how the various accreditation statuses are determined and applied. The agency’s policies do not demonstrate that it has an effective mechanism to ensure that programs are limited to a timeframe not to exceed two years to correct deficiencies. Also, it is not clear why the agency would require a deferral of one year in order to receive additional information on which to make a determination, thus providing up to three years to a program to come into compliance with agency standards.
Staff determination: The agency does not meet the requirements of this section. The agency must provide additional information and evidence demonstrating its enforcement of two-year timelines for its programs to come into compliance with the agency's standards. |
Analyst Remarks to Response: |
In response to the draft staff analysis, the agency provided sample letters demonstrating that its action letters notify programs/institutions of the two-year time limit for correcting deficiencies. While the agency provided evidence that it notifies programs/institutions of the two-year time limit, it did not provide evidence that it enforces the two-year time limit. More documentation is needed in this area.
While not addressed under this section, in 602.20(b) the agency clarifies that it only allows a deferral of up to one year in cases where the deferral will not put the program/institution past the two-year time limit for bringing itself into compliance.
Staff determination: The agency does not meet the requirements of this section. The agency must document that it enforces a two-year time limit for its programs/institutions to bring themselves into compliance with the agency's standards.
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(b) If the institution or program does not bring itself into compliance within the specified period, the agency must take immediate adverse action unless the agency, for good cause, extends the period for achieving compliance.
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The agency has no policy addressing this in the 2012 version of its standards. As noted in the previous section, the agency's 2007 standards document has a policy that is noncompliant. The agency has not demonstrated that it has established criteria for granting extensions for good cause that it uses as a basis for granting an extension in rare and unusual circumstances. Neither has the agency demonstrated that it takes immediate adverse action to withdraw accreditation in instances that the program does not come into compliance with agency standards.
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate that it has established a policy and criteria for granting extensions for good cause that it uses as a basis for granting an extension in rare and unusual circumstances and demonstrate its application of good cause extensions, as applicable, or that the agency takes an immediate adverse action. |
Analyst Remarks to Response: |
As noted in the previous section, the agency has clarified that it only implements deferrals in order to obtain additional information in cases where the deferral will not result in the program/institution exceeding the two-year time limit to bring itself into compliance. However, deferrals do not fall under the ED definition of adverse actions. Therefore, it is not clear how these deferrals relate to extensions for good cause, nor whether the agency has policies regarding extensions for good cause that ensure that such extensions are only granted in unusual circumstances and for limited periods of time.
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate that it has policies that specifically address extensions for good cause, as well as criteria that ensure the extensions are only granted in unusual circumstances and under limited timeframes.
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§602.22 Substantive change. |
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(a) If the agency accredits institutions, it must maintain adequate substantive change policies that ensure that any substantive change to the educational mission, program, or programs of an institution after the agency has accredited or preaccredited the institution does not adversely affect the capacity of the institution to continue to meet the agency's standards. The agency meets this requirement if--
(1) The agency requires the institution to obtain the agency's approval of the substantive change before the agency includes the change in the scope of accreditation or preaccreditation it previously granted to the institution; and
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As a Title IV gatekeeper for an institution, the agency is required to address this criterion.
The agency has a comprehensive substantive policy that it applies to its accredited programs and institutions. The preface to the policy specifies that the agency requires prior approval of substantive changes before the change can be included in the program's accredited status. The agency's standards manual further specifies under Section 1.II.D.3. that substantive change applications must be submitted to the council and the program/institution must obtain council approval of the change prior to implementing it. However, the agency did not provide any documentation related to the implementation of this policy.
Staff determination: The agency does not meet the requirements of this section. The agency must provide documentation of its approval of various substantive changes. |
Analyst Remarks to Response: |
The agency states in its response that it has supplied sample substantive change documents for staff review. However, no documents were attached to the link that the agency provided under Exhibit 81.
Staff determination: The agency does not meet the requirements of this section. The agency must provide documentation of its approval of various substantive changes.
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(2) The agency's definition of substantive change includes at least the following types of change:
(i) Any change in the established mission or objectives of the institution.
(ii) Any change in the legal status, form of control, or ownership of the institution.
(iii) The addition of courses or programs that represent a significant departure from the existing offerings of educational programs, or method of delivery, from those that were offered when the agency last evaluated the institution.
(iv) The addition of programs of study at a degree or credential level different from that which is included in the institution's current accreditation or preaccreditation.
(v) A change from clock hours to credit hours.
(vi) A substantial increase in the number of clock or credit hours awarded for successful completion of a program.
(vii) If the agency's accreditation of an institution enables the institution to seek eligibility to participate in title IV, HEA programs, the entering into a contract under which an institution or organization not certified to participate in the title IV, HEA programs offers more than 25 percent of one or more of the accredited institution's educational programs.
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The agency's definition of substantive changes include all of the types of substantive changes except for the requirement in 602.22(a)(2)(i) related to a change in objectives. The agency's definition includes a change in mission, without addressing a change in objectives. Further, the agency provided no documentation to demonstrate any substantive change requests it has received in these required areas.
Staff determination: The agency does not meet the requirements of this section. The agency must add the required change in objectives to its definitions of substantive change. The agency must also provide documentation of its review of various types of substantive change requests. |
Analyst Remarks to Response: |
The agency is in the process of amending its policies and will address the requirements of this section in its report. As in the previous section, staff notes that there are no documents attached to the link for Exhibit 81.
Staff determination: The agency does not meet the requirements of this section. The agency must add the required change in objectives to its definitions of substantive change. The agency must also provide documentation of its review of various types of substantive change requests. |
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(viii) (A) If the agency's accreditation of an institution enables it to seek eligibility to participate in title IV, HEA programs, the establishment of an additional location at which the institution offers at least 50 percent of an educational program. The addition of such a location must be approved by the agency in accordance with paragraph (c) of this section unless the accrediting agency determines, and issues a written determination stating that the institution has--
(1) Successfully completed at least one cycle of accreditation of maximum length offered by the agency and one renewal, or has been accredited for at least ten years;
(2) At least three additional locations that the agency has approved; and
(3) Met criteria established by the agency indicating sufficient capacity to add additional locations without individual prior approvals, including at a minimum satisfactory evidence of a system to ensure quality across a distributed enterprise that includes--
(i) Clearly identified academic control;
(ii) Regular evaluation of the locations;
(iii) Adequate faculty, facilities, resources, and academic and student support systems;
(iv) Financial stability; and
(v) Long-range planning for expansion.
(B) The agency's procedures for approval of an additional location, pursuant to paragraph (a)(2)(viii)(A) of this section, must require timely reporting to the agency of every additional location established under this approval.
(C) Each agency determination or redetermination to preapprove an institution's addition of locations under paragraph (a)(2)(viii)(A) of this section may not exceed five years.
(D) The agency may not preapprove an institution's addition of locations under paragraph (a)(2)(viii)(A) of this section after the institution undergoes a change in ownership resulting in a change in control as defined in 34 CFR 600.31 until the institution demonstrates that it meets the conditions for the agency to preapprove additional locations described in this paragraph.
(E) The agency must have an effective mechanism for conducting, at reasonable intervals, visits to a representative sample of additional locations approved under paragraph (a)(2)(viii)(A) of this section.
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The agency’s policy does not address the requirement of this criterion which allows an agency to pre-approve the establishment of additional locations at an accredited institution, but only after conducting a review that meets the requirements of this criterion.
Staff determination: The agency does not meet the requirements of this section. The agency must address the requirements of this criterion to include documentation of its application of the protocol, or it needs to state that it will not allow prior approvals for the establishment of additional locations. |
Analyst Remarks to Response: |
The agency will address the requirements for this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must address the requirements of this criterion to include documentation of its application of the protocol, or it needs to state that it will not allow prior approvals for the establishment of additional locations.
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(3) The agency's substantive change policy must define when the changes made or proposed by an institution are or would be sufficiently extensive to require the agency to conduct a new comprehensive evaluation of that institution.
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The agency’s policy does not address the requirement of this criterion, which requires the agency to define (in policy/protocol) those circumstances under which the substantive changes occurring at its accredited institution are sufficiently extensive to require the agency to conduct a new comprehensive evaluation of that institution and to demonstrate its application of the policy.
Staff determination: The agency does not meet the requirements of this section. The agency must establish appropriate policy/protocol and demonstrate its effective application of the requirements of this criterion regarding when new evaluations are required. |
Analyst Remarks to Response: |
The agency's policy does not address the requirement of this criterion, which requires the agency to define (in policy/protocol) those circumstances under which the substantive changes occurring at an accredited institution are sufficiently extensive to require the agency to conduct a new comprehensive evaluation of that institution and to demonstrate its application of the policy.
Staff determination: The agency does not meet the requirements of this section. The agency must establish an appropriate policy/protocol and demonstrate its effective application of the requirements of this criterion regarding when new evaluations are required.
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(b) The agency may determine the procedures it uses to grant prior approval of the substantive change. However, these procedures must specify an effective date, which is not retroactive, on which the change is included in the program's or institution's accreditation. An agency may designate the date of a change in ownership as the effective date of its approval of that substantive change if the accreditation decision is made within 30 days of the change in ownership. Except as provided in paragraph (c) of this section, these procedures may, but need not, require a visit by the agency.
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The agency’s policy (referenced) does not address the requirement of this criterion, which requires the agency to establish procedures for approving substantive changes that must include a specified effective date of the council’s approval (which is NOT retroactive) and the council’s inclusion of the substantive change in the institution’s grant of accreditation.
Staff determination: The agency does not meet the requirements of this section. The agency must establish appropriate policy/protocol and demonstrate its effective application of the requirements of this criterion to establish and demonstrate effective protocols for approving substantive changes that include specific effective dates that are not retroactive. |
Analyst Remarks to Response: |
The agency will respond to the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must establish appropriate policy/protocol and demonstrate its effective application of the requirements of this criterion to establish and demonstrate effective protocols for approving substantive changes that include specific effective dates that are not retroactive. |
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(c) Except as provided in (a)(2)(viii)(A) of this section, if the agency's accreditation of an institution enables the institution to seek eligibility to participate in Title IV, HEA programs, the agency's procedures for the approval of an additional location where at least 50 percent of an educational program is offered must provide for a determination of the institution's fiscal and administrative capacity to operate the additional location. In addition, the agency's procedures must include--
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The agency's Policy 1.B.5 and 1.B.6 require that a program requesting a substantive change provide information in its substantive change request application regarding any changes in its administrative organization or governance structure, as well as identification of resources to support the change, including financial resources.
No documentation was provided to support the agency's policies under this section.
Staff determination: The agency does not meet the requirements of this section. The agency must provide documentation of its implementation of its approval of substantive changes; specifically, how it determines the fiscal and administrative capacity of the institution to operate the additional location. |
Analyst Remarks to Response: |
In its response to the draft analysis, the agency stated that it had provided additional documentation as to how it determines fiscal and administrative capacity. However, as under previous sections, no documents were uploaded for Exhibit 81.
Staff determination: The agency does not meet the requirements of this section. The agency must provide documentation of its implementation of its approval of substantive changes; specifically, how it determines the fiscal and administrative capacity of the institution to operate the additional location.
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(c)(1) A visit, within six months, to each additional location the institution establishes, if the institution--
(i) Has a total of three or fewer additional locations;
(ii) Has not demonstrated, to the agency's satisfaction, that it has a proven record of effective educational oversight of additional locations; or
(iii) Has been placed on warning, probation, or show cause by the agency or is subject to some limitation by the agency on its accreditation or preaccreditation status;
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The agency's Policy 1.C. under Council Action specifies that a site visit will be conducted within six months to each additional location if the institution meets the requirements specified under this section. However, the agency did not provide any evidence of the substance of the site visit review conducted at an additional location nor provide any documentation of its implementation of its policy.
Staff determination: The agency does not meet the requirements of this section. The agency must provide additional information and documentation of the substance of the site visit review conducted at an additional location. |
Analyst Remarks to Response: |
In response to the draft staff analysis, the agency provided a sample site visit report that was recently conducted regarding an additional location, as well as the action letter regarding the review. The visit resulted in the approval of the program at the additional location. However, this is not evidence of a review within the requirements of this criterion for a site visit to take place within six months since the campus (additional location) was established and opened in 2009 and the visit was conducted in 2011.
Staff determination: The agency does not meet the requirements of this section. The agency must provide additional information and documentation that it conducts site visits to newly established additional locations within the required six month timeframe.
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(c)(2) An effective mechanism for conducting, at reasonable intervals, visits to a representative sample of additional locations of institutions that operate more than three additional locations; and
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The agency's Policy 1.C specifies that the agency may conduct visits to additional sites of programs that have more than three locations at reasonable intervals, but does not specify a sampling technique or how those sites to be visited will be determined.
Staff determination: The agency does not meet the requirements of this section. The agency must provide additional information regarding its sampling requirements for site visiting additional locations at an institution having more than three locations. |
Analyst Remarks to Response: |
The agency states that it has not yet had an occasion to approve more than two additional locations; therefore, the council has not addressed this requirement. Nevertheless, this section requires that agencies have a mechanism in place to deal with such a circumstance. Therefore, the agency must address the requirements of this section.
Staff determination: The agency does not meet the requirements of this section. The agency must provide additional information regarding its sampling requirements for site visiting additional locations at an institution having more than three locations.
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(c)(3) An effective mechanism, which may, at the agency's discretion, include visits to additional locations, for ensuring that accredited and preaccredited institutions that experience rapid growth in the number of additional locations maintain educational quality.
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The agency's Policy 1.C on Council Action specifies that the agency MAY conduct visits to additional sites of programs that experience rapid growth in order that the agency may determine that educational quality is maintained. The requirement under this criterion is that the agency have effective mechanisms that ensure that the additional locations of an institution experiencing rapid growth maintain educational quality.
The agency has not provided sufficient narrative addressing the conditions that will require a site visit or what alternative mechanisms it will use to ensure education quality under the conditions of this criterion. The agency has provided no documentation of effective application of mechanisms to address the requirement of this criterion.
Staff determination: The agency does not meet the requirements of this section. The agency must provide additional narrative addressing the conditions that will require a site visit or what alternative mechanisms it will use to ensure educational quality under the conditions of this criterion. The agency needs to also provide documentation of effective application of mechanisms to address the requirement of this criterion. |
Analyst Remarks to Response: |
The agency states that it has not yet had a situation involving rapid growth, so the council has not addressed this requirement. Nevertheless, this section requires that agencies have a mechanism in place to deal with such a circumstance. Therefore, the agency must address the requirements of this section.
Staff determination: The agency does not meet the requirements of this section. The agency must provide additional narrative addressing the conditions that will require a site visit or what alternative mechanisms it will use to ensure educational quality under the conditions of this criterion. The agency needs to also provide documentation of effective application of mechanisms to address the requirement of this criterion.
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§602.23 Operating procedures all agencies must have. |
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(a) The agency must maintain and make available to the public, upon request, written materials describing--
(1) Each type of accreditation and preaccreditation it grants;
(2) The procedures that institutions or programs must follow in applying for accreditation or preaccreditation;
(3) The standards and procedures it uses to determine whether to grant, reaffirm, reinstate, restrict, deny, revoke, terminate, or take any other action related to each type of accreditation and preaccreditation that the agency grants;
(4) The institutions and programs that the agency currently accredits or preaccredits and, for each institution and program, the year the agency will next review or reconsider it for accreditation or preaccreditation; and
(5) The names, academic and professional qualifications, and relevant employment and organizational affiliations of--
(i) The members of the agency's policy and decision-making bodies; and
(ii) The agency's principal administrative staff.
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ED staff verified that most of the information specified in this section is readily available to the public via the agency's web site; however, evidence of (5) did not appear to be available on the web site. CCE Policy 151 indicates that information specified in this criterion is made available to the public "upon request".
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate that it makes available to the public the names, academic and professional qualifications, and relevant employment and organizational affiliations of the members of the agency's policy and decision-making bodies; and the agency's principal administrative staff. |
Analyst Remarks to Response: |
In its response to the draft analysis, the agency referred staff to its web page. In viewing the site, a link to the agency's administrative staff provides the viewer with the name and a picture of each staff member. No additional information is provided, except that it is noted that the agency's president holds a D.C. degree. No information is provided regarding academic and professional qualifications or relevant employment or organizational affiliations of staff as specified under 602.23(a)(5)(ii).
The link to the councilor directory provides the person's name, degree(s), location by city and state, and, for some of the members, the place of employment. No information is provided regarding where degrees were awarded, professional qualifications, or organizational affiliations, and in some cases no information is provided as to employment affiliation as specified under 602.23(a)(5)(i).
While the agency does not have to provide all of the required information on its website, the agency must be able to demonstrate that it provides this information, on request. The documents provided by the agency as examples of what it provides, on request, do not include all of the required information.
No information is provided regarding the agency's appeals panel members as specified under 602.23(a)(5)(i).
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate that it makes available to the public the names, academic and professional qualifications, and relevant employment and organizational affiliations of the members of the agency's policy and decision-making bodies; and the agency's principal administrative staff. |
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(c) The accrediting agency must--
(1) Review in a timely, fair, and equitable manner any complaint it receives against an accredited institution or program that is related to the agency's standards or procedures. The agency may not complete its review and make a decision regarding a complaint unless, in accordance with published procedures, it ensures that the institution or program has sufficient opportunity to provide a response to the complaint;
(2) Take follow-up action, as necessary, including enforcement action, if necessary, based on the results of its review; and
(3) Review in a timely, fair, and equitable manner, and apply unbiased judgment to, any complaints against itself and take follow-up action, as appropriate, based on the results of its review.
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The agency's complaint policies are addressed under its Policy 64 on Complaints. Complaints may be submitted regarding the agency (including councilors, site team visitors, staff, or other representatives), agency standards or policies, or accredited programs.
ED staff is concerned that the agency's complaint policy states that it has both "informal" and "formal" complaint process components. It is unclear how the informal complaint process component would meet the requirements either for a timely review or for the program/institution to have an opportunity to respond to the complaint. Further, it appears that the complainant has no option but to submit to the informal process, absent its stated lack of time constraints, prior to moving to the formal complaint process. This has the potential to greatly add to the time period in which the complaint remains unresolved. The formal complaint process component does meet the requirements of this section with regard to how it addresses time constraints, input from the program/institution, and enforcement action by the Council. As stated previously, the complaint policy also applies to complaints against the agency itself.
The agency provided no documentation related to the handling of any complaints.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its complaint process to address the concerns described in the analysis of this criterion and provide documentation illustrating its effective review and resolution of complaints under these processes.
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Analyst Remarks to Response: |
The agency will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its complaint process to address the concerns described in the analysis of this criterion and provide documentation illustrating its effective review and resolution of complaints under these processes.
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§602.24 Additional procedures certain institutional accreditors must have. |
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If the agency is an institutional accrediting agency and its accreditation or preaccreditation enables those institutions to obtain eligibility to participate in Title IV, HEA programs, the agency must demonstrate that it has established and uses all of the following procedures:
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(b) Change of ownership.
The agency must undertake a site visit to an institution that has undergone a change of ownership that resulted in a change of control as soon as practicable, but no later than six months after the change of ownership.
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The agency's Policy 1.A.2 notes that a change in ownership is considered a substantive change requiring prior approval. However, the agency's Policy 1.C. specifies that in instances of substantive changes involving a change in ownership a site visit is "at the discretion of the Council" (p. 3). The agency's policy does not require a site visit within six months.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policies to require a site visit within six months to institutions that have undergone a change in ownership and provide evidence of its conduct of a site visit after a change in ownership. |
Analyst Remarks to Response: |
The agency will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policies to require a site visit within six months to institutions that have undergone a change in ownership and provide evidence of its conduct of a site visit after a change in ownership. |
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(c) Teach-out plans and agreements.
(1) The agency must require an institution it accredits or preaccredits to submit a teach-out plan to the agency for approval upon the occurrence of any of the following events:
(i) The Secretary notifies the agency that the Secretary has initiated an emergency action against an institution, in accordance with section 487(c)(1)(G) of the HEA, or an action to limit, suspend, or terminate an institution participating in any title IV, HEA program, in accordance with section 487(c)(1)(F) of the HEA, and that a teach-out plan is required.
(ii) The agency acts to withdraw, terminate, or suspend the accreditation or preaccreditation of the institution.
(iii) The institution notifies the agency that it intends to cease operations entirely or close a location that provides one hundred percent of at least one program.
(iv) A State licensing or authorizing agency notifies the agency that an institution's license or legal authorization to provide an educational program has been or will be revoked.
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The requirement of this section is that the agency have a teach-out plan policy that includes the requirement that the agency require an institution it accredits to submit a teach- out plan upon the occurrence of events listed in the criterion. The agency's policies relative to teach-outs does not clearly require a teach-out plan, nor does it include the events listed in the criterion.
Although the agency submitted documentation prepared by a program on the receiving end of a teach-out, the agency's policies do not appear to address this section's requirements regarding teach-out plans. The only reference to teach-outs in the policies referenced in the agency's narrative involve teach-out agreements, not teach-out plans.
Staff determination: The agency does not meet the requirements of this section. The agency must establish policies that require teach-out plans and that include the requirement that an institution submit a teach-out plan on the occurrence of the events listed in the criterion. |
Analyst Remarks to Response: |
The agency will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must establish policies that require teach-out plans and that include the requirement that an institution submit a teach-out plan on the occurrence of the events listed in the criterion. |
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(2) The agency must evaluate the teach-out plan to ensure it provides for the equitable treatment of students under criteria established by the agency, specifies additional charges, if any, and provides for notification to the students of any additional charges.
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Under this requirement the agency is expected to have procedures/protocol for the evaluation of teach-out plans that includes agency-established criteria by which it assesses that the proposed teach-out plan provides for equitable treatment of students, specifies additional changes and provides (appropriate ) notification to students of those charges. The agency's policy does not address how the agency will evaluate a teach-out plan in a manner that complies with the requirement of this criterion.
Staff determination: The agency does not meet the requirements of this section. The agency must establish and demonstrate the effective application of its evaluation of teach-out plans that includes agency-established criteria by which it assesses that the proposed teach-out plan provides for equitable treatment of students, specifies additional changes and provides (appropriate ) notification to students of those charges. |
Analyst Remarks to Response: |
The agency is proposing an amendment to its policies and so will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must establish and demonstrate the effective application of its evaluation of teach-out plans that includes agency-established criteria by which it assesses that the proposed teach-out plan provides for equitable treatment of students, specifies additional changes and provides (appropriate ) notification to students of those charges. |
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(3) If the agency approves a teach-out plan that includes a program that is accredited by another recognized accrediting agency, it must notify that accrediting agency of its approval.
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The agency did not address how its policies require the notification of other agencies regarding teach-out plans. Further, the documentation provided was a cover letter that included no information regarding any teach-out plans.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policies to include the requirement that it will notify other agencies of teach-out plans it has approved,as appropriate, and demonstrate effective application as applicable. |
Analyst Remarks to Response: |
The agency is proposing an amendment to its policies and so will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policies to include the requirement that it will notify other agencies of teach-out plans it has approved,as appropriate, and demonstrate effective application as applicable. |
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(5) The agency must require an institution it accredits or preaccredits that enters into a teach-out agreement, either on its own or at the request of the agency, with another institution to submit that teach-out agreement to the agency for approval. The agency may approve the teach-out agreement only if the agreement is between institutions that are accredited or preaccredited by a nationally recognized accrediting agency, is consistent with applicable standards and regulations, and provides for the equitable treatment of students by ensuring that--
(i) The teach-out institution has the necessary experience, resources, and support services to--
(A) Provide an educational program that is of acceptable quality and reasonably similar in content, structure, and scheduling to that provided by the institution that is ceasing operations either entirely or at one of its locations; and
(B) Remain stable, carry out its mission, and meet all obligations to existing students; and
(ii) The teach-out institution demonstrates that it can provide students access to the program and services without requiring them to move or travel substantial distances and that it will provide students with information about additional charges, if any.
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The agency policy requires that in order for institutions/programs to enable students to complete their program in the event a program ceases operations, teach-out agreements must be submitted for review and approval.
The agency’s policy establishes that only teach-outs with another CCE-accredited program will be approved. The agency's policy requires that the teach-out program have the experience, resources and support services needed to provide an educational experience that is similar in content, structure, and scheduling and that it provide students access to its services without requiring them to move or travel significant distances. However, there is no evidence that the agency has developed a protocol for the review of a teach-out agreement, nor developed guidance on what it expects the institution/program to submit as a teach-out agreement.
The agency needs to develop appropriate guidance and review protocol for receiving and reviewing teach-out agreements that includes an assessment of the teach-out criteria under 602.24(5) (i and ii) and demonstrate its effective review and approval of a teach-out agreement in the context of the criterion.
Staff determination: The agency does not meet the requirements of this section. The agency must develop appropriate guidance and review protocol for receiving and reviewing teach-out agreements that includes an assessment of the teach-out criteria under 602.24(5) (i and ii) and demonstrate its effective review and approval of a teach-out agreement in the context of the criterion.
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Analyst Remarks to Response: |
The agency is proposing an amendment to its policies and so will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must develop appropriate guidance and review protocol for receiving and reviewing teach-out agreements that includes an assessment of the teach-out criteria under 602.24(5) (i and ii) and demonstrate its effective review and approval of a teach-out agreement in the context of the criterion.
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(d) Closed Institution.
If an institution the agency accredits or preaccredits closes without a teach-out plan or agreement, the agency must work with the Department and the appropriate State agency, to the extent feasible, to assist students in finding reasonable opportunities to complete their education without additional charges.
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The agency's Policy 2 on Teach-out Agreements in the Case of Closure or Cessation of Operation specifies that when a program's governing body decides to cease operations, the agency will work with state and federal agencies to try to ensure that students are given opportunities to complete their education without incurring additional charges. However, the agency has not provided evidence of its effective application of this policy.
Staff determination: The agency does not meet the requirements of this section. The agency needs to provide evidence of its effective application of its policy to work with state and federal agencies to ensure that, in the case of a program closing without a teach-out agreement, students are given opportunities to complete their education without incurring additional charges.
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Analyst Remarks to Response: |
The agency is proposing an amendment to its policies and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency needs to provide evidence of its effective application of its policy to work with state and federal agencies to ensure that, in the case of a program closing without a teach-out agreement, students are given opportunities to complete their education without incurring additional charges.
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(e) Transfer of credit policies.
The accrediting agency must confirm, as part of its review for initial accreditation or preaccreditation, or renewal of accreditation, that the institution has transfer of credit policies that--
(1) Are publicly disclosed in accordance with §668.43(a)(11); and
(2) Include a statement of the criteria established by the institution regarding the transfer of credit earned at another institution of higher education.
(Note: This criterion requires an accrediting agency to confirm that an institution's teach-out policies are in conformance with 668.43 (a) (11). For your convenience, here is the text of 668.43(a) (11):
“A description of the transfer of credit policies established by the institution which must include a statement of the institution's current transfer of credit policies that includes, at a minimum –
(i) Any established criteria the institution uses regarding the transfer of credit earned at another institution; and
(ii) A list of institutions with which the institution has established an articulation agreement.”)
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The agency's Standard G: Student Admissions under Characteristic 3 requires that an institution/program have published policies governing the acceptance of prior academic credit or transfer of credit from one DCP to another. The agency's policy 6.3 on Minimum Admission Requirements further specifies the agency's requirements related to transfer of credits into any of its accredited programs/institutions.
However, the agency's policy does not address the associated requirements under §668.43(a)(11):
(i) Any established criteria the institution uses regarding the transfer of credit earned at another institution; and
(ii) A list of institutions with which the institution has established an articulation agreement.
Additionally, there is no evidence that the agency assesses the transfer of credit policies for their compliance with the requirements of this criterion during the review for accreditation.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its requirements related to transfer of credit to include the requirements under §668.43(a)(11) and demonstrate its effective application of this requirement during accreditation reviews. |
Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its requirements related to transfer of credit to include the requirements under §668.43(a)(11) and demonstrate its effective application of this requirement during accreditation reviews. |
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(2) In reviewing and evaluating an institution's policies and procedures for determining credit hour assignments, an accrediting agency may use sampling or other methods in evaluation, sufficient to comply with paragraph (f)(1)(i)(B) of this section.
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The agency did not address the requirement of this section. Under this criterion the agency is to have credit hour policies that require it to conduct an effective review and evaluation of the reliability and accuracy of the institution's assignment of credit hours. The review is required to include an assessment of an institution's policies and procedures for determining credit hour and the institution's application of its policies. The agency is required to make a determination whether the institution's assignment of credit hours conforms to commonly accepted practices. The agency is to have a methodology for conducting its evaluation. While the agency stated that it has procedures for this requirement, the citation it referenced did not address the requirement of this criterion.
The agency needs to demonstrate that it has, and effectively applies, procedures that address the requirements as stated.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence that it has and effectively applies policies and procedures for the review and determination of the reliability and accuracy of an institution's credit hour assignments.
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Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence that it has and effectively applies policies and procedures for the review and determination of the reliability and accuracy of an institution's credit hour assignments.
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(3) The accrediting agency must take such actions that it deems appropriate to address any deficiencies that it identifies at an institution as part of its reviews and evaluations under paragraph (f)(1)(i) and (ii) of this section, as it does in relation to other deficiencies it may identify, subject to the requirements of this part.
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As noted in the prior section, the agency does not have any policies related to credit hour review.
Staff determination: The agency does not meet the requirements of this section. The agency must develop and demonstrate that it effectively applies policies related to credit hour review and their enforcement. |
Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must develop and demonstrate that it effectively applies policies related to credit hour review and their enforcement. |
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(4) If, following the institutional review process under this paragraph (f), the agency finds systemic noncompliance with the agency’s policies or significant noncompliance regarding one or more programs at the institution, the agency must promptly notify the Secretary.
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As noted in prior sections, the agency does not have any policies related to credit hour review or the requirement to notify the Department of any systemic noncompliance with the agency’s credit hour policies on credit hour assignment.
Staff determination: The agency does not meet the requirements of this section. The agency must develop and effectively apply policies related to credit hour review, enforcement, and notification that include the requirement to notify the Department of any systemic noncompliance with the agency’s credit hour policies on credit hour assignment.
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Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must develop and effectively apply policies related to credit hour review, enforcement, and notification that include the requirement to notify the Department of any systemic noncompliance with the agency’s credit hour policies on credit hour assignment.
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§602.25 Due process |
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(f) Provides an opportunity, upon written request of an institution or program, for the institution or program to appeal any adverse action prior to the action becoming final.
(1) The appeal must take place at a hearing before an appeals panel that--
(i) May not include current members of the agency's decision-making body that took the initial adverse action;
(ii) Is subject to a conflict of interest policy;
(iii) Does not serve only an advisory or procedural role, and has and uses the authority to make the following decisions: to affirm, amend, or reverse adverse actions of the original decision-making body; and
(iv) Affirms, amends, reverses, or remands the adverse action. A decision to affirm, amend, or reverse the adverse action is implemented by the appeals panel or by the original decision-making body, at the agency's option. In a decision to remand the adverse action to the original decision-making body for further consideration, the appeals panel must identify specific issues that the original decision-making body must address. In a decision that is implemented by or remanded to the original decision-making body, that body must act in a manner consistent with the appeals panel's decisions or instructions.
(2) The agency must recognize the right of the institution or program to employ counsel to represent the institution or program during its appeal, including to make any presentation that the agency permits the institution or program to make on its own during the appeal.
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The has a written policy for taking action on appeals. A program may file a notice to appeal within 20 days of receiving an adverse action.
The agency's policies under Criteria for Selecting an Appeals Panel specify that the panel members may not include anyone who was involved with the appellant program, was part of the review process, or current councilors. This section specifies that the program may disqualify panel members it believes to have conflicts of interest, but does not address the agency’s obligation to have and apply its conflict of interest policies as it does for other decision-making bodies.
The agency's policies provide for all of the types of decisions listed in the criterion and do specify that a decision that is remanded by the panel must include specific issues to be addressed. The policy also states that the Council must act in a manner consistent with the panel's decisions or instructions.
The agency's Policy 8, under a section on Hearing Format, specifies that the appellant may be represented by legal counsel.
The agency has stated that it has not had an appeal under its current policies as it has not had an appeal in the past 9+ years .
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate that its appeals panel members are subject to its conflict-of-interest policy.
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Analyst Remarks to Response: |
The agency stated its original intent to implicitly include appeals panel members under the category of “other CCE representatives” in its application of its conflict of interest policy. The Department staff believes this is insufficient. The appeal panel is a recognized decision-making body and as such, its decisions can impact access to federal funds. As the appeal panel members convene irregularly, the necessity to apply the agency’s conflict of interest policies may be overlooked if the cohort is not explicitly identified in the conflict of interest policies.
The agency also notes in its response that it is in the process of clarifying its current conflict-of-interest policy to specify that the policy specifically includes appeals panel members. However, the policy has not yet been formally adopted, and the agency will therefore address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must demonstrate that its appeals panel members are subject to its conflict-of-interest policy.
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§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--
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((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
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The agency's Policy 111.4 specifies that the agency will make a brief summary regarding the adverse actions (listed under its Policy 111.2) available within 60 days to ED, all state licensing boards, and the public.
The agency's policy specifies that the summary will include any comments that the affected program may wish to make, but the policy does not clarify the obligation of the agency to provide evidence that it has offered the affected institution the opportunity to provide comments.
Staff determination: The agency does not meet the requirements of this section. The agency must clarify the obligation of the agency to provide evidence that it has offered the affected institution the opportunity to provide comments. |
Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must clarify the obligation of the agency to provide evidence that it has offered the affected institution the opportunity to provide comments. |
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§602.27 Other information an agency must provide the Department. |
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(a)(6) The name of any institution or program it accredits that the agency has reason to believe is failing to meet its Title IV, HEA program responsibilities or is engaged in fraud or abuse, along with the agency's reasons for concern about the institution or program; and
(a)(7) If the Secretary requests, information that may bear upon an accredited or preaccredited institution's compliance with its Title IV, HEA program responsibilities, including the eligibility of the institution or program to participate in Title IV, HEA programs.
(b) If an agency has a policy regarding notification to an institution or program of contact with the Department in accordance with paragraph (a)(6) or (a)(7) of this section, it must provide for a case by case review of the circumstances surrounding the contact, and the need for the confidentiality of that contact. Upon a specific request by the Department, the agency must consider that contact confidential.
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The agency's policy 20: Notification of U.S. Secretary of Education Regarding Fraud, Abuse or Failure to Meet Title IV Responsibilities, specifies that if the agency has reason to believe that any of its programs is failing to meet its Title IV responsibilities, the agency will provide the Secretary the name of the program and the reason for its concern within 15 days of its discovery of the concern. It further states that it will notify the program at the same time of its intent to notify the Secretary. The agency states that it has not had occasion to enforce this policy and therefore has no related documentation.
The agency's policy does not address the confidentiality requirement specified in 602.27(b).
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policy regarding the reporting of Title IV fraud and abuse to reflect the confidentiality requirements under 602.27(b). |
Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policy regarding the reporting of Title IV fraud and abuse to reflect the confidentiality requirements under 602.27(b). |
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§602.28 Regard for decisions of States and other accrediting agencies. |
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(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.
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The agency's Policy 46: Adverse Decisions by Other Accrediting Organizations and State Agencies specifies that the agency is "concerned" when another accrediting or state agency "denies, revokes, or places sanctions" on one of the agency's accredited programs/institutions. An "adverse decision" made by another agency will be reviewed by the Council, which will investigate whether the program/institution remains in compliance with the CCE standards and may require a site visit, reports, or further information.
ED staff has concerns that the agency's policy, as written, does not specifically address pending actions by another agency, nor does it specifically address this section's terminology regarding suspension, withdrawal, or termination. The policy also fails to address another agency's actions related to a program/institution that holds preaccreditation, rather than full accreditation.
Staff determination: The agency does not meet the requirements of this section. The agency needs to amend the language of its policy to more closely conform to the requirements of this section. |
Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency needs to amend the language of its policy to more closely conform to the requirements of this section. |
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(c) The agency may grant accreditation or preaccreditation to an institution or program described in paragraph (b) of this section only if it provides to the Secretary, within 30 days of its action, a thorough and reasonable explanation, consistent with its standards, why the action of the other body does not preclude the agency's grant of accreditation or preaccreditation.
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The agency's Policy 46, as described in the previous section, also specifies that within 30 days, the agency will provide ED with an explanation consistent with its standards as to why a negative action by another agency against a program/institution does not preclude CCE from granting initial or renewed accreditation to that program/institution. The agency does not grant pre-accreditation.
However, the agency did not provide documentation of its application of its policy.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of the application of its policy on providing explanations of over-riding decisions.
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Analyst Remarks to Response: |
The agency was requested to provide documentation of its application of this section. The agency’s response that it is “working on this area” does not address the staff concern.
Staff determination: The agency does not meet the requirements of this section. The agency must provide evidence of the application of its policy on providing explanations of over-riding decisions.
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(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.
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As discussed in the prior sections, the agency's requirements regarding adverse actions by other agencies are addressed in its Policy 46. However, the agency's policy does not include any time constraints associated with a prompt review of adverse actions by other agencies. Further, the policy specifies that it is the program's/institution's responsibility to notify CCE of the adverse action; the policy does not address information regarding adverse actions that CCE might receive from another agency or source.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policies to clarify that it will promptly investigate information it receives from any source regarding negative accrediting actions taken by other agencies and provide evidence of its prompt review of a program that is located in an institution that is the subject of an adverse action or pending action or of a CCE-accredited institution that is subject to a pending or final action. |
Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policies to clarify that it will promptly investigate information it receives from any source regarding negative accrediting actions taken by other agencies and provide evidence of its prompt review of a program that is located in an institution that is the subject of an adverse action or pending action or of a CCE-accredited institution that is subject to a pending or final action. |
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(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.
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The agency's Policy 111: Notification of CCE Accrediting Decisions specifies that the agency will provide information within 30 days to all state licensing boards and appropriate accrediting agencies regarding final denial, withdrawal, suspension, revocation or termination of accreditation. While this policy would presumably cover most instances in which another agency would need information regarding a CCE-accredited program/institution, it does not specifically state that such information will be available upon request outside the regular notification process, nor does it cover the possibility that another agency that might not be included in the automatic notification process might need information regarding accreditation status or adverse actions.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policy to clearly state that information regarding accreditation status or adverse accrediting actions will be available to other agencies upon request and demonstrate effective application of the policy. |
Analyst Remarks to Response: |
The agency reports that it is working on the issues identified in the draft staff analysis and will address the requirements of this section in its report.
Staff determination: The agency does not meet the requirements of this section. The agency must amend its policy to clearly state that information regarding accreditation status or adverse accrediting actions will be available to other agencies upon request and demonstrate effective application of the policy. |
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PART III: THIRD PARTY COMMENTS |
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| Staff Analysis of 3rd Party Written Comments |
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The Department received approximately 4000 comments with regard to this agency from chiropractors, chiropractic educators and administrators, chiropractic students, chiropractic patients, and members of state boards. Of the comments received, thirty were in support of the agency and included practitioners, representatives of state boards, and the public. The remaining comments were in opposition to the agency. Many of the oppositional comments were form letters and petitions and were therefore quite similar, and in some cases identical, in content.
The comments in favor of the agency supported the agency's medically-based approach and stated that the commenters felt that the agency had duly considered all viewpoints in its most recent review of its standards. These commenters included representatives of two state boards.
The comments in opposition to the agency were based largely upon a long-standing philosophical disagreement within the chiropractic community and continue a pattern of oppositional comments that have been received by the Department each time this agency has been reviewed for recognition over the years. One commenter referred to this as "the political and philosophical issues which have divided the chiropractic profession for the last 115 years." This debate centers largely on whether it is appropriate for chiropractors to dispense drugs or perform surgery. The oppositional commenters feel that CCE is moving the profession toward more medically-based training (and therefore practice) and strongly oppose that approach.
It is not the Department's responsibility to take sides in this ongoing philosophical discussion; rather, the Department may only evaluate the agency's compliance with regard to the Secretary's Criteria for Recognition. Some of the opposing comments were related to the Criteria, whereas some were not.
The opposing comments largely centered around the following concerns:
(1) the elimination of the term "subluxation" from the agency's standards:
This is a professional issue within the chiropractic community. Staff concludes that it is beyond the purview of the Department to dictate to any agency what its curriculum requirements and accreditation standards should be.
(2) the removal from the standards of the specification "without drugs or surgery" when describing chiropractic treatment:
Staff concludes that it is beyond the purview of the Department to dictate to any agency what its curriculum requirements and accreditation standards should be.
(3) concern that the comments of those opposed to a medically-based approach to chiropractic study and practice were not considered during the course of the agency's most recent standards review process:
The staff review concludes that the agency did not provide evidence of its consideration of all comments it received during the course of its standards review process. It should be noted that an agency is required to consider all comments, but is not required to implement all of the comments or suggestions it receives. [602.21(c)]
(4) opposition to the Doctor of Chiropractic Medicine or equivalent degree:
Staff concludes that it is beyond the purview of the Department to dictate to any agency the type of degree/credentials it chooses to accredit. The staff review of the agency’s petition determined, however, that the CCE is not accrediting any programs beyond its recognized scope.
(5) lack of representation of the opposing commenters' philosophy among the agency's current council members:
Staff review found that council members are independently selected by member programs and by other council members based on selection criteria established by the agency in accordance with its bylaws. [602.14(b)]
(6) lack of satisfaction with the accreditation history of the one institution that the agency accredits:
The agency's reevaluation process was examined during the course of the staff review. It should be noted that no complaints have been received by the Department from the institution itself regarding the accuracy of its reevaluation by the agency. [602.19(a)]
(7) concern over the percentage of chiropractic student defaults in the Department of Health and Human Services' (HHS) Health Education Assistance Loans (HEAL) program, which the commenters attribute to student dissatisfaction with medically-based chiropractic education programs:
This concern is not related to the Criteria. It should be noted that the HEAL program has not disbursed funds since 1998. According to an HHS web site, thirteen years after the HEAL program ceased funding there are 523 former chiropractic students who are currently in default. This would not appear to be a high default rate considering that there are approximately 50,000 licensed chiropractors in the U.S., based upon information obtained from the U.S. Bureau of Labor Statistics web site.
(8) concern regarding attrition rates in the profession, which the opposition again attributes to dissatisfaction with the profession's perceived shift to more medically-based treatment options:
This concern is not related to the Criteria. The Department does not monitor information regarding attrition rates in any profession. Again, it is noted that there are approximately 50,000 licensed chiropractors in the U.S. according to the U.S. Bureau of Labor Statistics.
In conclusion, some of the oppositional commenters stated that they would like to establish an additional chiropractic education accrediting body that would be more closely aligned with their chiropractic philosophy. That is an option that those commenters may wish to explore.
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| Agency Response to 3rd Party Comments |
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The agency concurs with the staff analysis regarding the comments in all areas noted. However, we would like to provide comments and supporting documentation regarding item (3) where the USDE staff cite the following:
The staff review concludes that the agency did not provide evidence of its consideration of all comments it received during the course of its standards review process. It should be noted that an agency is required to consider all comments, but is not required to implement all of the comments or suggestions it receives. [602.21(c)]
It is not difficult to explain and evidence the process but all events occurred from 2006 through 2011 and with that in mind, there is alot of evidence and documents to review. We will attempt to provide as clear and concise a reply as possible.
The policy that drives the revision process is contained in CCE Policy 23, this policy clearly outlines the five year revision process that the Standards Review Task Force (SRTF), CCE Committees and the Council itself followed since 2006 up to the approval of the final document (January 2012 Standards) at the January 2011 Council Meeting.
This is also evidenced in many other documents provided within the Renewal Petition to include; Exhibit 43, SRTF Memos-Emails, Exhibit 44, SRTF Meeting Agendas, Exhibit 45, Council Meeting Minutes RE SRTF, Exhibit 46, CCE Timeline of Events during Review Process, Exhibit 47, Public Comment Announcements, Exhibits 48-52, Draft Standards from 2007-2010 and also Exhibit 53, Review of Public Comments Summary for 2009 & 2010.
An important point should be made to clarify the certain misunderstanding and characterization of the “almost 4,000 comments from the public” as noted in many of the comments received. The following facts are submitted to help clear up this misunderstanding.
The exact number of comments received in the CCE Administrative Office by the deadline date regarding the July 23, 2010 CCE Announcement, Revision to the CCE Standards Public Comment, totaled 3,909. The comments submitted were both for and against the draft document. To better clarify, the following examples are submitted:
1. One (1) original letter regarding opposition of two areas of the Standards was submitted and 755 supporting documents followed regarding the same items. In every case, the original letter was copied by all 755 supporters and submitted as an exact copy or with a cover letter. In both the original letter submitted and all 755 supporting documents, there was only opposition to the Standards with no suggested revision that the task force could evaluate as to another option.
2. In another example, there were over 2,000 letters (all copied from the same original) regarding other areas and allegations that a few groups and individuals THOUGHT the task force was going to change but at no time during the process did the task force change these areas or show any evidence that they were going to change these areas. It was clearly a misunderstanding by a minority of individuals and groups in these areas and as it turned out, the allegations were untrue. As a matter of fact, the current version of the revised CCE Standards, January 2012 edition does not indicate any of the changes in the aforementioned comments from the over 2,000 letters. The 2,000 letters were a direct result of alleged changes with no evidence to support the false claims…unfortunately, these 2,000 individuals were instructed to submit copied letters and failed to do their own due diligence and review the documents posted on the website and mentioned in the announcements.
3. Another example to provide some clarification is the 375 separately submitted comments that were in favor of the revised version of the CCE Standards in certain areas and/or the document in its entirety. These documents were original and submitted from 375 different organizations and/or individuals. Many of the comments also complimented the task force on the long arduous process that began in 2006 and now was coming to an end in 2011, while still others were generally appreciative of the work the task force had provided to the Council and the profession. However, not all of these comments were accepted by the task force as some also delved into areas that were not within the purview of CCE or accreditation related.
So, as the task force moved through the entire process over the five year period, there were a few noteworthy documents to mention. Provided for your review are a series of Memorandums sent to the SRTF (6/6/10, 10/29/10 & 11/12/10) and the Council (12/3/10). These memos highlight the meticulous review of each and every comment received from the July 2010 Public Comment results. These documents certainly evidence that all comments were considered according to both CCE and USDE requirements.
We also would like to clarify the process of revision of the CCE Standards due to the many comments that refer to the process but not correctly. CCE Policy 23 clearly identifies the steps of the process and the following information outlines and evidences the process was followed and completed in a timely and efficient manner.
In sequential order, the following documents were posted to the CCE website along the process to provide the public with the opportunity to comment as outlined in USDE regulations and CCE policies and procedures:
1. Draft #2, CCE Standards (completed, June 2009; posted to website September 4, 2009)
2. CCE Announcement, Public Comment for Standards (posted to website, September 4, 2009)
3. Deadline date for public comments to be received in CCE Administrative Office, November 4, 2009
4. Public Comments reviewed by SRTF and Council, December 2009 & January 2010
5. Final Draft (Draft #3), CCE Standards (completed, June 2010; posted to website July 23, 2010)
6. CCE Announcement, Public Comment for Standards (posted to website, July 23, 2010)
7. Deadline date for public comments to be received in CCE Administrative Office, September 24, 2010
8. Public Comments reviewed by SRTF and Council, October & December 2010
In all instances, the SRTF was provided a summary of public comment and also the public comments themselves to use as a tool in the evaluation and revision of the new CCE Standards and its processes. Just as with all accrediting agencies and the processes of revision of the Standards, the Department of Education requires, and we quote from the USDE Criteria for Recognition, CFR 602.21(c), Review of Standards:
…the agency must --
(1) Provide notice to all of the agency’s relevant constituencies, and other parties who have made their interest known to the agency, of the changes the agency proposes to make;
(2) Give the constituencies and other interested parties adequate opportunity to comment on the proposed changes; and
(3) Take into account any comments on the proposed changes submitted timely by the relevant constituencies and by other interested parties.
The agency welcomes any interested party to visit the CCE Administrative Office, with appropriate notification for scheduling purposes, to provide explanation and education in the processes and requirements the agency must adhere to. We are confident that our processes in place meet the necessary requirements and are always willing to share our information in accordance with our procedures.
Our Council Chair has submitted comments (attached) as an FYI. |
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| Staff Analysis of Agency Reponse to 3rd Party Comments |
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| Staff notes that the agency provided additional information and documentation regarding its standards review process, and specifically its consideration of third-party comments, under sections 602.21(a),(b), and (c) of its response to the draft staff analysis. After reviewing the additional information and documentation provided by the agency under those sections, staff found that the agency had met the requirements that it consider (but not necessarily accept) the third-party comments it received during its standards review process. |
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