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U.S. Department of Education

Staff Report
to the
Senior Department Official
on
Recognition Compliance Issues

RECOMMENDATION PAGE

1.
Agency:   Commission On Collegiate Nursing Education (2000/2012)
                  (The dates provided are the date of initial listing as a recognized agency and the date of the agency’s last grant of recognition.)
 
2.
Action Item:   Petition for Continued Recognition
 
3.
Current Scope of Recognition:   The accreditation of nursing education programs in the United States, at the baccalaureate, masters and doctoral degree levels, including programs offering distance education.
 
4.
Requested Scope of Recognition:   The accreditation of nursing education programs in the United States, at the baccalaureate, master’s, doctoral, and certificate levels, including programs offering distance education.
 
5.
Date of Advisory Committee Meeting:   June, 2017
 
6.
Staff Recommendation:   Continue the agency's current recognition and require the agency to come into compliance within 12 months, and submit a compliance report 30 days after the 12 month period that demonstrates the agency's compliance with the issues identified below.

In addition, the agency must cease its practice of retroactive accreditation; remove all reference to retroactive accreditation from its website, policy / procedures manuals, and accreditation standards no later than 60 days after the senior Department official makes the decision on the agency's recognition. The agency must provide documentary evidence of these actions to the Department. If such documentation is not provided the agency will continue to be out of compliance and will be scheduled for review in accordance with 34 CFR §602.33 at the next available NACIQI Meeting.

Regarding the agency's request for an expansion of scope: While the agency continues to be out of compliance with the Secretary's Criteria for Recognition, Department staff has been able to determine that CCNE has adequate standards and the capability to accredit certificate programs in nursing. CCNE has also provided documentation demonstrating its review and approval of nurse certificate programs. It is also important to note that CCNE is already approved to accredit nursing programs at the doctoral level and these nurse certificate programs appear to be below the doctoral level.
 
7.
Issues or Problems:   It does not appear that the agency meets the following sections of the Secretary’s Criteria for Recognition. These issues are summarized below and discussed in detail under the Summary of Findings section.

-- The agency does not meet the requirements of this section of the criteria. The agency must amend agency procedures and any standards and policies that reference or reflect the use of retroactive dating of accreditation actions back to the first day of the program’s most recent on-site evaluation and demonstrate training has occurred for all entities involved in accreditation activities on this amendment. [§602.15(a)(2)]

-- The agency does not meet the requirements of this section of the criteria. The agency must amend procedures and any standards and policies that reference or reflect the use of retroactive dates of accreditation actions back to the first day of the program’s most recent on-site evaluation and demonstrate with evidence of full cycles of review of this change for a compliance determination to be made for enforcement timelines. [§602.20(a)]

-- The agency does not meet the requirements of this section of the criteria. The agency must provide evidence of the implementation of its good cause policy. [§602.20(b)]

-- The agency does not meet the requirements of this section of the criteria. The agency needs to demonstrate with documentation that the standards, procedures and websites it uses to determine whether to grant, reaffirm, reinstate, restrict, deny, revoke, terminate, or take any other action related to each type of accreditation that the agency grants is compliant with the Secretary’s criteria as well as maintained and made available to the public. [§602.23(a)]



EXECUTIVE SUMMARY

 
 

PART I: GENERAL INFORMATION ABOUT THE AGENCY

 
The Commission on Collegiate Nursing Education (CCNE or the Commission), an autonomous arm of the American Association of Colleges of Nursing (AACN), accredits baccalaureate, master's, and doctoral degree nursing education programs located in public and private universities and senior colleges throughout the United States. At the time the agency submitted its petition for continued recognition, the agency had accredited, 1438 nursing programs (729 baccalaureate programs, 460 master’s programs, 249 doctoral programs) per their current scope of recognition, representing 49 states, the District of Columbia, and Puerto Rico.

The agency accredits nursing education programs located in colleges and universities accredited by recognized accrediting agencies offering baccalaureate, master's, and doctoral degrees. As a programmatic accreditor, the agency does not need to meet the eligibility requirements for Title IV program participation. However, the Secretary’s recognition enables the nursing education programs accredited by CCNE to establish eligibility to participate in programs administered by the U.S. Department of Health and Human Services, the U.S. Department of Veterans Affairs and other non-Higher Education Act Federal programs.

The agency had no complaints during the recognition period.
 
 
Recognition History
 
The agency's review for continued recognition in 2012 resulted in submission of a compliance report regarding one outstanding issue which was satisfied in 2014. The agency's review for continued recognition is the subject of this analysis.


PART II: SUMMARY OF FINDINGS

 
§602.15 Administrative and fiscal responsibilities
(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;

 
The agency utilizes several committees, on-site evaluators, and policy /decision-making bodies within the accreditation processes. Policy and decision-making related to compliance with agency standards for accreditation is the responsibility of the agency's Board. The multiple committees make recommendations to the Board on various issues; on-site evaluators analyze nursing programs to verify that programs are meeting agency standards; and the hearing committee, which is an independent review body of the agency, considers appeals of adverse actions of accreditation (exhibits 2, 5 and 15). However, resumes/curriculum vitae's of the Board and the Hearing Committee were not provided to assess whether their qualifications meet the outlined requirements of the agency bylaws, policies, procedures and the criteria.

The Board consists of thirteen members who are comprised of six representatives from agency-affiliated nursing programs, which include three chief nurse administrators; three representatives from the field of professional nursing practice; two professional consumers who represent employers of health care professionals; and two public consumers (uploaded document 2). The Board is the final authority on all policy and accreditation matters/actions (exhibit 2 and 19-21). Board members are selected from position-specific qualifications; and oriented to the activities of the agency, including its organization, accreditation process, standards, policies and procedures containing distance education, prior to attending a Board meeting for new members (exhibit 22).

The accreditation review committee (ARC) serves as the primary review body for nursing programs seeking initial or continued accreditation and makes recommendations about accreditation actions to the Board. The ARC, appointed by the Board chair, consists of at least four members of the Board and at least four individuals from outside of the Board (uploaded document 3). The ARC offers recommendations to the Board after review of the self-study, the team report, and the program's response to the team regarding action to be taken. The ARC members are trained on their purpose, roles, and responsibilities, including distance education, as evidenced in the orientation-committees agenda (exhibit 23 and 36).

The on-site evaluation teams are determined by the type of program being reviewed consisting of a team leader for each type of visit plus two team members to evaluate a single degree program; three team members to evaluate two degree programs; and five team members to evaluate three degree programs. The agency may add an additional team member when reviewing a post-graduate APRN certificate program in addition to a degree program. Evaluators are selected through a nomination process after submission of an evaluator questionnaire, CV; and letters of recommendation. An evaluators is appointed to a team if the member is knowledgeable of the type and specialty of the program being reviewed; an educator with knowledge in one or more areas of nursing education and program development; and a practicing nurse with knowledge in at least one area of nursing practice relevant to the program under review. The agency provides training for all evaluators on agency strategies, policies, procedures and standards for the accreditation review process, including certificate programs and distance education, via training materials and webinars (exhibits 14-18 and uploaded document 5).

Other committees involved in the accreditation processes of the agency, not mentioned in this section but included in the procedures for the agency, include the report review committee and the hearing committee. The report review committee (RRC) RRC is the primary body to review annual report data, continuous improvement progress reports, compliance reports, special reports, and other reports submitted by accredited nursing programs; monitors the programs between evaluations; and offers recommendations to the Board regarding action to be taken. The RRC, appointed by the chair of the Board, consists of at least three members of the Board and at least four individuals from outside of the Board (uploaded document 3). The RRC members are trained on their purpose, roles, and responsibilities, including distance education, yearly and members hold staggered appoints to maintain institutional knowledge (exhibit 23, and 36).

The hearing committee serves as an independent review body of the agency to handle appeals of adverse actions. The hearing committee, appointed by the chair of the Board, consists of three to five members depending on the review, which includes at least one practicing nurse, one academic, and one public representative (exhibit 59). The hearing committee may not include a member of the Board, advisory group, evaluation team or committee involved in the review of the program leading to the adverse action; must have been trained as an on-site evaluator for the agency; and have at least 10 years of experience in nursing practice/education (exhibit 2). However, formal training materials for the hearing committee have not been provided as evidence of their training.

Lastly, the agency's website and Procedures for Accreditation of Baccalaureate and Graduate Nursing Programs states "CCNE accreditation actions are retroactive to the first day of the program's most recent CCNE on-site evaluation" (uploaded document 6). The use of retroactive dates for accreditation decisions is non-complaint with the Secretary's criteria, except in the case of 602.22 (b) Change of Ownership for Title IV gatekeepers, which this agency is not.

In an effort to ensure the agency came into compliance with the Secretary's criteria, the Analyst and the Accreditation Director reached out to the agency via conference call and explained the need to revise its policy. The Director of the Accreditation Group followed up with correspondence to the agency in July of 2016 and the agency responded in September 2016 with reasoning for the its use. However the Accreditation Group sent a final letter in November of 2016 informing the agency that they remain non- compliant with the use of retroactive dating of accreditation actions back to the first day of the program's most recent on-site evaluation (uploaded documents 7-9).

This communication further stated that the agency needed to provide in its renewal petition documentary evidence that it has amended its policies and no longer awards accreditation retroactive to the date of the site visit. However, the agency has not addressed the requested change in the petition narrative and evidence provided within the petition demonstrates that the agency is still non-compliant. Specifically, the Procedures for Accreditation of Baccalaureate and Graduate Nursing Programs continue to reference the use of the retroactive dates as policy (exhibit 2). Thus, the training of agency representatives on the accreditation process, which includes training on the agency Procedures, is also non-compliant with the Secretary's criteria.

Analyst Remarks to Response:
The agency has provided the resumes of the Board and the Hearing Committee members to demonstrate that qualified individuals comprise the decision making bodies of the agency (exhibits 10, 13-14, and Analyst upload). The agency also provided the Hearing Committee orientation agenda to demonstrate formal training of this committee.

However, the agency remains non-compliant with this criterion. The agency actively trains agency representatives (Board/Committee members, site evaluators, etc.) on its Procedures, which includes the following non-compliant language on page six "CCNE accreditation actions are effective as of the first day of that program's most recent CCNE on-site evaluation." The Procedures originally submitted with the agency petition and the updated Procedures provided to the Department on May 14, 2017 continue to contain this language. During the on-site observation by the Analyst in April 2017, the Chair of the on-site review team provided a PowerPoint presentation to the program leadership and staff on next steps, which included a slide stating the aforementioned language from the agency's Procedures. The Department of Education's expectation regarding the accreditation effective date used by accrediting agencies has been provided as reference (Analyst upload) and is discussed in detail in 602.23(a). The agency remains non-compliant with this criterion based on the fact that it continues to conduct t training of its representatives on retroactive accreditation which continues to be stated in the agency policy publications.
 

§602.20 Enforcement of standards

(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.

 
The agency procedures demonstrates an adequate review of the nursing program through the submission of the program's self-study; a report from the review of compliance with agency standards by the evaluation team; the accreditation review committee's review of the evaluation report and development of an accreditation recommendation for Board consideration; and then final decisions made by the Board (exhibits 1 and 2). Once the Board makes the final decision the agency is notified to submit a continuous improvement progress report (CIPRs) at the mid-point of the awarded accreditation term for the program to demonstrate continuous compliance with agency standards. The agency provided examples of a CIPR report, reminder letters and guidelines as evidence, however, the date on the special report has been redacted, which prevents the Department staff from determining if the enforcement timelines required by this criterion have be exceeded (exhibits 49-51).

If the program is found out of compliance with a key element of a standard, when accreditation is granted or continued, the program is notified and required to submit a compliance report. However, it is unclear to Department staff as to the length of time required for a program to come into compliance since the narrative states 'typically afforded one year to submit the compliance report', however a defined period of time is not included in the agency procedures for compliance reports. This is important since the agency’s policy regarding compliance reports must not allow a program to exceed the timelines required by this criterion. In addition, the agency has not provided a compliance report to evidence this process.

If the program, at the time accreditation is granted or continued, does not comply with one or more of the standards for accreditation, the program must submit a special report. The Board provides a letter to the program identifying the non-compliant accreditation standard(s) along with the requirement that the program must demonstrate compliance within 2 years or face adverse action from the Board. The agency may extend the 2 year period for good cause, which is utilized if the program has made substantial progress toward compliance and the quality of the program is not in jeopardy. However, the agency has not defined the length of time for good cause extensions in their policies and procedures. The agency also provided an example of a special report as evidence. As noted previously, the date on the special report has been redacted, which prevents Department staff from determining if the enforcement timelines required by this criterion have been exceeded (exhibits 2, 55 and 56).

Finally, the agency's report review committee reviews the aforementioned reports and develops recommendations for the Board regarding continued compliance in the case of CIPRs; resolution of concerns for compliance reports; and standards being met/not met for special reports. The agency may also issue a one year show cause directive to a program to respond to when substantive questions and concerns are raised regarding program compliance with standards, key elements and/or adherence to agency procedures. The agency does not consider this directive as an adverse action since it is issued to the program as a statement of concern, however, depending upon the programs response, an adverse action may be taken.

Analyst Remarks to Response:
The agency provided an example of a continuous improvement progress report (CIPR) report demonstrating compliance with the agency requirements within its procedures for a program to submit a CIPR. The agency has also provided an explanation of the length of time its policy allows for an extension for good cause and has updated the agency's Procedures approved by the Board to reflect this revision, which was provided to the Department May 14, 2017. Specifically, the updated procedures state "Compliance reports are normally submitted 1 year, but not later than 15 months, following the Board's determination that the program has a compliance concern for one or more key elements" (exhibit 22).

The agency then provided an explanation in the narrative for the program identifiers included in the updated evidence (exhibits 01-06) and the dates it selected to remove from redaction. The staff determination required this information be included in the response to the draft analysis for a compliance determination to be made. Upon further review of the exhibits in their entirety with the agency updates, additional clarity has been afforded on the agency's practices of enforcement timelines. Department staff has found the agency non-compliant for retroactive accreditation in section 602.23(a); however, since the agency has been practicing retroactive accreditation, it is unclear what date the agency has been using to calculate its enforcement timelines. Because of this, it is possible that documentation could indicate noncompliance for more than 2 years.

Also, the updated special report example (exhibit 04) provided as evidence for this criteria includes the issue identified in 602.16(a)(1) of granting accreditation with what appears to be deficiencies. As previously noted, the agency may provide an adequate explanation at the NACIQI meeting; therefore, the agency is not being found non-compliant at this time. If not, Department staff will address this issue with the agency in accordance with 34 CFR §602.33 and will require the agency to appear before the NACIQI at a future meeting, if necessary.
 

(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.
 
The agency procedures requires programs to submit a special report if, at the time accreditation is granted or continued, the program does not comply with one or more of the standards for accreditation (exhibit 2). The Board provides a letter to the program identifying the non-compliant accreditation standard(s) along with the requirement that the program must demonstrate compliance within 2 years or face adverse action from the Board. The agency may extend the 2 year period for good cause, which is utilized if the program has made substantial progress toward compliance and the quality of the program is not in jeopardy. However, the agency has not defined the length of time for a good cause extension in their policies and procedures.

The agency also provided an example of a special report as evidence, however, the critical months of the special report are blacked out, which impedes on the staff's analysis of the evidence with agency policies and procedures (exhibits 55 and 56).



Analyst Remarks to Response:
The agency narrative describes the changes made to their Procedures in regards to extension’s for good cause. The agency procedures have been updated, as of May 14, 2017, to state that “The Board determines the appropriateness of an extension of time for good cause on a case by case basis, but the extension of time for good cause may not exceed 18 months beyond the 2-year period for achieving compliance.”

The agency then provided an updated special report example (exhibit 04) with selected dates removed from redaction. The staff determination then required the agency to provide evidence of a good cause extension. Although the agency provided the updated document for (exhibit 04), the documentation does not clearly demonstrate evidence of a good cause extension, nor the narrative explain whether or not the agency has or has not had a good cause extension during the recognition period. There is no language in the letter that specifically states the program has be placed on an extension for good cause. The absence of this language from the letter within the updated example does not demonstrate the application of an extension for good cause, thus the Department staff continues to find the agency non-compliant with the criteria.
 

§602.23 Operating procedures all agencies must have.
(a) The agency must maintain and make available to the public 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.

 
The agency has attested that there have been no changes to the policies or practices since its last review before the NACIQI for the criteria; however, the Department has found the agency to be non-compliant with 602.23 (a)(3) of the criteria. The agency’s website and Procedures for Accreditation of Baccalaureate and Graduate Nursing Programs states “CCNE accreditation actions are retroactive to the first day of the program’s most recent CCNE on-site evaluation” (uploaded document 1). The use of retroactive dates for accreditation decisions is non-complaint with the Secretary’s criteria, except in the case of 602.22 (b) Change of Ownership for Title IV gatekeepers, which this agency is not.

In an effort to ensure the agency came into compliance with the Secretary’s criteria, the Analyst and the Accreditation Director reached out to the agency via conference call and explained the need to revise its policy. The Director of the Accreditation Group followed up with correspondence to the agency in July of 2016 and the agency responded in September 2016 with reasoning for the its use. However, upon consult with the Office of General Counsel, the Accreditation Group sent a final letter in November of 2016 informing the agency that they remain non- compliant with the use of retroactive dating of accreditation actions back to the first day of the program’s most recent on-site evaluation (upload 2-4).

This communication further stated that the agency needed to provide in its renewal petition documentary evidence that it has amended its policies and no longer awards accreditation retroactive to the date of the site visit. However, the agency has not addressed the requested change in the petition narrative and evidence provided within the petition demonstrates that the agency is still non-compliant. Specifically, the Procedures for Accreditation of Baccalaureate and Graduate Nursing Programs continues to reference the use of the retroactive dates as policy (exhibit 2) and the full cycle of reviews contain effective dates in the program decision letters further demonstrating this practice, thus the agency remains non-compliant (exhibits 4, 33, 34, 44).

During an observation of the agency during the petition review, Department staff further discovered the retroactive reference is still posted on the agency website (see uploaded document 1).

Analyst Remarks to Response:
Regarding the agency’s practice of retroactive accreditation, and the agency’s rationale for doing so, the agency has provided documentation such as letters from 3 organizations and from 3 of the 53 recognized accrediting agencies (this does not include state approval agencies for vocational and nurse education). However, Department staff’s position on the matter of retroactive accreditation has not changed.

The definition of accreditation found in 34 Code of Federal Regulation (CFR) 602.3, “Definitions applicable to this part,” defines accreditation as “the status of public recognition that an accrediting agency grants to an educational institution or program that meets the agency’s standards and requirements”. Only the accrediting agency’s decision-making body can make accreditation decisions or determine if an institution or program meets its accreditation standards. Accreditation decisions are made on the date the accrediting agency’s decision-making body meets, and not the date that the site team conducted its evaluation of the institution or program (34 CFR 602.15 clearly distinguishes evaluation bodies and decision-making bodies). Backdating the accreditation approval date to the date of the site visit essentially gives the site team decision-making authority. An institution or program that is awaiting an accreditation or pre-accreditation decision from the agency’s decision-making body does not hold that status a day, a week, a month, a year or any time earlier than that decision is made.

Accreditation affords institutions and programs certain privileges, such as access to Federal funding. Allowing institutions or programs access to Federal funds (grants or Title IV) based on a backdated accreditation approval date is problematic and would allow institutions and programs premature access to federal dollars. It could also allow access to Federal funds that the institution or program would not have qualified for, but for the backdating of the accreditation approval date.

As discussed previously with the agency, the only place in the Secretary’s Criteria for Recognition where retroactive accreditation is even discussed is regarding changes of ownership. The requirements relative to changes of ownership are found in 34 CFR 602.22 (b) and stipulate that “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”. These are very specific requirements outlining the length and situation where retroactive approval is allowed.

We want to emphasize that if retroactive accreditation were viewed as allowable, as the agency asserts, there would be no basis for limiting how far back would be acceptable. For example, an accrediting agency could backdate the accreditation approval to the date the institution or program initially completed its application for accreditation. More troubling is the fact that throughout the accrediting community there are occurrences where the decision-making body’s decision differs from the site team’s recommendation, or the decision-making body substantially disagrees with the site team’s recommendation. A policy of backdating creates what may be false expectations among students and other stakeholders. In addition, the decision-making body may have access to more information than the site team when making its accreditation decision, as required by 34 CFR 602.17 (e). Automatically backdating the accreditation approval date may ignore corrections the decision-making body required the institution or program to make to achieve compliance with the agency’s standards. Retroactive accreditation is most problematic in the situations where an accrediting agency’s decision-making body defers its decision. Backdating the accreditation approval date totally ignores the deferral period. Some agencies also employ review committees, which review the site team report and make accreditation recommendations to the decision-making body and whose processes lengthen the time between the site visit and the review of the decision-making body. Therefore, as stated previously, the Department staff’s decision has not changed regarding this matter.

Finally, if the major issue for backdating the accreditation approval date is to allow students to graduate from accredited programs, accrediting agencies could have additional decision meetings to accommodate those occurrences. Those meetings could be virtual to mitigate travel expenses to agencies. Other agencies are able to accommodate this challenge.

The Department of Education’s expectation regarding the accreditation effective date used by accrediting agencies has also been included as Upload A as reference. The June 6, 2017 letter sent to the accrediting agencies from the Director of the Accreditation Group was vetted and supported by the Senior Leadership of the Department of Education.
 
 

PART III: THIRD PARTY COMMENTS

 
Staff Analysis of 3rd Party Written Comments
The Department received seven comments recommending the continued recognition of the agency. The commenters were all external constituents of the agency. The comments support the agency's rigorous standards that measure the quality of nursing programs in all areas of 602.16; competency of representatives, 602.15(a)(2); educator/practitioner representatives, 602.15(a)(4); and the new scope of recognition to include certificate programs (602.12(b).