American Physical Therapy Association 02/07/2018 11/07/2017 Final Review Renewal Petition

U.S. Department of Education

Staff Report

to the

Senior Department Offical

on

Recognition Compliance Issues


Recommendation Page



  1. American Physical Therapy Association
  2. Renewal Petition
  3. The accreditation and preaccreditation ("Candidate for Accreditation") in the United States of physical therapist education programs leading to the first professional degree at the master's or doctoral level and physical therapist assistant education programs at the associate degree level and for its accreditation of such programs offered via distance education.
  4. Same as above.
  5. February 07, 2018
  6. 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.
  7. 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 must provide documentation to demonstrate it has taken an adverse action and enforced the timeframes required by this section. [§602.20(a)] -- The agency must provide documentation to demonstrate that it clearly communicates to a program when it grants an extension for good cause. [§602.20(b)]

Executive Summary



Part I: General Information About The Agency

The American Physical Therapy Association (APTA) is a professional association of more than 80,000 physical therapists, physical therapy assistants, and students of physical therapy. The Commission on Accreditation in Physical Therapy Education (CAPTE) of the APTA is a programmatic accreditor. CAPTE membership is voluntary and its principal purpose is to accredit higher education programs. CAPTE accredits and preaccredits physical therapist (PT) education programs leading to the first professional degree at the master’s or doctoral level and physical therapist assistant (PTA) education programs at the associate degree level. CAPTE accreditation of PT and PTA programs is required for access to the Scholarships for Disadvantaged Students (SDS) Program which was established via the Disadvantaged Minority Health Improvement Act of 1990, Section 737 of the Public Health Service Act. As a programmatic, non-Title IV eligible accreditor, CAPTE is not required to meet the separate and independent requirements in the Secretary’s Criteria for Recognition. CAPTE currently accredits 202 PT programs, 274 PTA programs, and 74 preaccredited ("developing") programs throughout the United States, the District of Columbia, and its territories. In addition to the U.S. programs, the agency also recognizes PT programs in Canada and the United Kingdom, although these programs are outside the scope of the agency’s recognition by the Secretary.

Recognition History

The Commission on Accreditation in Physical Therapy Education (CAPTE) of the American Physical Therapy Association (APTA) was first recognized by the Secretary in 1977. In 1985, the Secretary granted an expansion of scope to the agency to include the preaccreditation of programs for the physical therapist and physical therapist assistant. The agency has been periodically reviewed and continued recognition has been granted after each review. The agency has evaluated programs offering courses using distance education methodology since 1994 and 1997 for the PT and PTA programs, respectively, and has been included within its scope since July 2002. CAPTE was last reviewed for continued recognition at the fall 2012 meeting of the National Advisory Committee on Institutional Quality and Integrity (NACIQI). Both Department staff and the NACIQI recommended to the senior Department official to continue the agency's recognition and require it to come into compliance within 12 months, and submit a compliance report that demonstrates the agency's compliance with the issues cited in the staff report. The senior Department official, Acting Assistant Secretary David Bergeron, concurred with the recommendations. The compliance report was reviewed and accepted by both Department staff and NACIQI at the spring 2014 meeting. Since the agency's last review, the Department has received no complaints and no 3rd party comments. In conjunction with agency's petition, Department staff reviewed the agency’s supporting documentation and observed a CAPTE meeting in April 2017.


Part II: Summary Of Findings

602.15(a)(2) Competency of Representatives

(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;


Qualifications of CAPTE members As outlined in agency's rules, CAPTE is both the policy- and decision-making body of the agency. CAPTE accomplishes its work via the use of three panels - PT panel, PTA panel, and central panel. CAPTE members are selected from the roster of site visitors, except the public members and consumer member. The agency's rules define the qualifications for the CAPTE members, thus ensuring that it includes educators, practitioners, and public members. The agency provided documentation about its current CAPTE members to demonstrate that they are qualified to fulfill their assigned roles. Qualifications of Site Visitors The agency's rules sets specific qualifications for site visitors, which include at least two years experience as an educator or a practitioner. The agency provided sample site visitor assessment forms and CVs, as well as the roster of all site visitors, to demonstrate that the agency obtains sufficient information to determine that individuals serving in this role meet the agency's qualifications requirements. The agency provided information and documentation of its comprehensive and on-going training program for CAPTE members and site visitors on their roles and responsibilities, as well as the standards, policies, and procedures of the agency, to include distance education. This information and documentation includes site visitor workshops, new member orientation, mentoring, on-site evaluation observations, an accreditation handbook and manual, and online and on-going training and resources. As an example, the agency provided documentation to confirm the training for site visitors on the new standards. On-site team chairs and candidacy site reviewers receive further training to fulfill their role. In addition, the agency reviews its process for consistency through the use of on-site evaluation assessments and staff review of CAPTE actions at each meeting. Qualifications of Appeals Panel Members The agency did not provide any information or documentation concerning the qualifications, selection, and training of appeals panel members.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided information and documentation on the qualifications, selection, and training of its appeals panel members. Per the agency's rules, appeal panel members are selected from the roster of site visitors and prior CAPTE members. The agency's rules define the qualifications for the appeal panel members, thus ensuring that it includes an educator, practitioner, and public member, as required by regulation. The agency provided documentation (attached) of its current appeal panel pool, as well as the members of the last two appeals held by the agency. The agency also provided information and documentation of its comprehensive training for appeal panel members.



602.15(a)(4) Educator/Practitioner Representatives

(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;


The agency states that the evaluation, policy, and decision-making bodies (site visitors, CAPTE members, and appeals panel pool) are comprised of both educators and practitioners, and represent the types of programs accredited by the agency. The agency provided documentation, in the form of rosters and resumes, that all bodies include such representation. Department staff observed the inclusion of both educators and practitioners at its meeting in April 2017. Although the agency provided its rules concerning the composition of site visitors and CAPTE (in Section 602.15(a)(2)), the agency did not provide the section of its rules that requires such representation on its appeals panel.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided its policies regarding the composition of the appeals panel (in Section 602.15(a)(2)). Per the agency's rules, appeal panel members are selected from the roster of site visitors and prior CAPTE members. The agency's rules define the qualifications for the appeal panel members, thus ensuring that it includes an educator, practitioner, and public member, as required by regulation. The agency also provided documentation (attached) to demonstrate implementation of the policy.



602.15(a)(5) Public Representatives

(5) Representatives of the public on all decision-making bodies; and


The agency's rules require that CAPTE include public representation - at least three public representatives - and provided its roster of CAPTE members (in Section 602.15(a)(2)) to demonstrate implementation. Department staff also observed the participation of public members during its meeting in April 2017. The agency states that, when convened, the appeals panel includes one representative of the public per the agency's rules. However, the agency did not provide the section of its rules that requires such representation. As included in the agency's rules, its definition of a public representative includes the requirements of the definition within the Secretary's Criteria for Recognition. The agency provided information and documentation on how it ensures that its public members meet both the agency's definition, as well as the Department's definition, for that position on CAPTE, but not on the appeals panel.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided its policies regarding the composition of the appeals panel (in Section 602.15(a)(2)), which states that, when convened, the appeals panel includes one representative of the public. The agency also included documentation (attached) on how it ensures that any public members on an appeals panel meet the required definition to demonstrate compliance with this section.



602.15(a)(6) Conflict of Interest

(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


The agency has a comprehensive policy on conflict of interest for CAPTE members, site visitors, staff, and appeal panel members, as included in the agency's rules. The policy cites specific instances of conflict of interest and provide guidance and mechanisms to address conflict of interest, such as recusal from site visits and the deliberation and decision-making process. The agency provided documentation of the use of such mechanisms cited to control against conflict of interest by all entities included in this section. Department staff observed the use of recusal during its meeting in April 2017. Although the agency stated that the policy is applicable to the entities listed in this section, it has not provided evidence of its application of the policy for all the entities listed, specifically appeals panel members, consultants, administrative staff, and other agency representatives, as applicable, as an effective control against conflicts of interest.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided documentation of implementation of its conflict of interest policy for all entities listed in this section. For the appeals panel, the agency provided documentation of a recusal of a potential member due to a conflict of interest, and a program noting conflicts of interest with potential members. For administrative staff, the agency provided documentation of recusal of staff during the discussion of a program due to a conflict of interest. The agency noted that it does not employ consultants nor any other agency representatives.



602.16(a)(1)(i) Student Achievement

(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:
(i) Success with respect to student achievement in relation to the institution's mission, which may include different standards for different institutions or programs, as established by the institution, including, as appropriate, consideration of course completion, State licensing examination, and job placement rates.


The agency's standards for student achievement are found within the PT and PTA standards and required elements. The agency applies the requirements to each program on an annual basis, and requires the program to address how effectively it meets its objectives and goals in its self-study. Within the evaluation process, each program must develop goals and associated outcomes related to the program's mission, and develop comprehensive, formal and on-going processes to assess achievement of the goals. In addition, each program must assess the performance of the graduates in their clinical practice, and have mechanisms to obtain feedback from graduates about how well prepared they were for practice and from employers about how well the graduates function in their clinical positions to inform curricula and student service improvement. With regards to outcomes data, the agency reviews graduation rates, licensure pass rates, and employment rates within the accreditation process. The annual report requires self-reporting of attrition rates and credentialing examination pass rates. On a two-year average, the agency has set a graduation rate of 60% for PTA programs and 80% for PT programs, licensure pass rate of 85%, and employment rate of 90%. Although the agency provided its outcomes benchmarks, the agency did not describe how it determined that the use of those rates are sufficiently rigorous to ensure that the agency is a reliable authority regarding the education provided by the programs it accredits. In addition, the agency states that CAPTE reserves the right to request that a program provide verification by an external source of a program’s student achievement data that CAPTE relies on, in part, in making an accreditation decision. Since this new requirement was effective January 2017, the agency had not had an opportunity to implement it prior to submitting its petition. Department staff requests that the agency submit documentation of implementation in response to the draft staff analysis, if available. The agency provided extremely limited documentation to demonstrate the consistent application of its student achievement standards. Specifically, the agency provided documentation of the applicable self-study sections and site visit report for one PT program. Although the documentation demonstrates the review of the program's student achievement assessment processes, procedures, and outcomes, the submission of the review of only one program does not demonstrate that the agency conducts such reviews consistently. In addition, the agency did not provide any documentation regarding the review of such information by CAPTE. Therefore, the agency must provide additional documentation to demonstrate systematic implementation of its student achievement standards.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation to demonstrate systematic implementation of its student achievement standards. The agency also provided additional information concerning how it determines that its standards and review of student achievement are sufficiently rigorous to ensure that the agency is a reliable authority regarding the education provided by the programs it accredits. Specifically, the agency described how it developed the current bright lines for student achievement rates, and the various processes both within an accreditation review and in between reviews to ensure compliance. In addition, the agency provided documentation of implementation of the new policy that allows CAPTE to request that a program provide verification by an external source of the program’s student achievement data.



602.16(a)(1)(ii) Curricula

(a)(1)(ii) Curricula.


The agency has clear and specific expectations regarding curricula contained in Section 2C of its standards and required elements for both the PT and PTA programs. The agency's standards are sufficiently detailed and clear to assess curricula in verifiable ways, and are applicable to all programs regardless of delivery mode (traditional or distance). The agency's standards clearly require a curriculum plan for every program at all levels that must be current with industry standards, have clearly defined competencies, and be sequenced and structured to allow for the achievement of those competencies. The curricular content requirements are primarily expressed in terms of the outcomes expected of the graduates related to entry-level practice for PTs and PTAs. The agency also provided information on how it assesses the validity of its curricula standards. The agency provided extremely limited documentation to demonstrate the consistent application of its curricula standards. Specifically, the agency only provided documentation of the applicable self-study sections and team report for one PTA program, and that program does not offer any distance education. Although the documentation demonstrates the program addressed the self-study in the area related to curricula and it was reviewed by the site team, the lack of a comprehensive review by the agency (to include CAPTE decision letter) in this area, as well as the documentation submission for only one program, does not demonstrate that the agency conducts reviews consistently and enforces its standards. Therefore, the agency must provide additional documentation to demonstrate systematic implementation of its curricula standards.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation to demonstrate systematic implementation of its curricula standards, as well as documentation of the review of programs offered via distance education. The documentation included review of such information by the CAPTE board.



602.16(a)(1)(iii) Faculty

(a)(1)(iii) Faculty.


The agency has clear and specific expectations regarding faculty contained in Section 4 of its standards and required elements for both the PT and PTA programs regardless of delivery mode (traditional or distance). The standards are sufficiently detailed and clear to assess faculty in verifiable ways. Specifically, the agency requires that all faculty members possess education, licensure, and clinical expertise backgrounds appropriate for their role in the program and to meet the mission of the institution. The agency provides the specific qualification expectations for each role (core faculty member, clinical faculty member, program administrator and academic coordinator of clinical education). In addition, the agency considers the faculty both individually and collectively to determine that they are capable of providing a quality PT or PTA program. The agency provided extremely limited documentation to demonstrate the consistent application of its faculty standards. Specifically, the agency only provided documentation of the applicable self-study sections and team report for one PT program. Although the documentation demonstrates the program addressed the self-study in the areas related to faculty and it was reviewed by the site team, the lack of a comprehensive review by the agency (to include CAPTE decision letter) in this area, as well as the documentation submission for only one program, does not demonstrate that the agency conducts reviews consistently and enforces its standards. Therefore, the agency must provide additional documentation to demonstrate systematic implementation of its faculty standards.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation to demonstrate systematic implementation of its faculty standards, as well as documentation regarding the review of such information by the CAPTE board.



602.16(a)(1)(iv) Facilities/Equipment/Supplies

(a)(1)(iv) Facilities, equipment, and supplies.


The agency has clear and specific expectations regarding facilities, equipment, and supplies contained in Section 8 of its standards and required elements for both the PT and PTA programs. The agency's standards are sufficiently specific to ensure that students have a safe and adequate space, and equipment and supplies to complete the program. The agency separately evaluates a program's library resources, laboratory equipment and supplies, and technology resources and infrastructure in this area. The standards are applicable to facilities, equipment, and supplies for all programs at all levels regardless of delivery mode (traditional or distance). The agency provided extremely limited documentation to demonstrate the consistent application of its facilities, equipment, and supplies standards. Specifically, the agency only provided documentation of the applicable self-study section and team report for one PTA program, and it does not appear from the documentation that the program offers any distance education. Although the documentation demonstrates the program addressed the self-study in the area related to facilities, equipment, and supplies and it was reviewed by the site team, the lack of a comprehensive review by the agency (to include CAPTE decision letter) in this area, as well as the documentation submission for only one program, does not demonstrate that the agency conducts reviews consistently and enforces its standards. Therefore, the agency must provide additional documentation to demonstrate systematic implementation of its facilities, equipment, and supplies standards.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation (in Section 602.16(a)(1)(ii) and (iii)) to demonstrate systematic implementation of its facilities, equipment, and supplies standards, as well as documentation regarding the review of such information by the CAPTE board.



602.16(a)(1)(v) Student Complaints

(a)(1)(v) Fiscal and administrative capacity as appropriate to the specified scale of operations.


The agency has clear and specific expectations regarding administrative and fiscal capacity contained in Section 8 of its standards and required elements for both the PT and PTA programs. The agency has sufficiently defined standards to assess the soundness of the financial and administrative capacity of its programs. The agency's standards require that programs have organizational and administrative structures that support the program's mission and goals. The agency provided extremely limited documentation to demonstrate the consistent application of its administrative and fiscal capacity standards. Specifically, the agency only provided documentation of the applicable self-study section and team report for one PTA program (and one request for additional information from a PT program based on review of the annual report). Although the documentation demonstrates the program addressed the self-study in the area related to administrative and fiscal capacity and it was reviewed by the site team, the lack of a comprehensive review by the agency (to include CAPTE decision letter) in this area, as well as the documentation submission for only one program, does not demonstrate that the agency conducts reviews consistently and enforces its standards. Therefore, the agency must provide additional documentation to demonstrate systematic implementation of its administrative and fiscal capacity standards.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation to demonstrate systematic implementation of its administrative and fiscal capacity standards, as well as documentation regarding the review of such information by the CAPTE board.



602.16(a)(1)(vi) Fiscal/Administrative Capacity

(a)(1)(vi) Student support services.


The agency has clear and specific expectations regarding student support services contained in Sections 2, 5, 6, & 8 of its standards and required elements for both the PT and PTA programs regardless of delivery mode (traditional or distance). The agency requires that programs inform students of and provide access to the student support services that are provided to other students in the institution, and separately evaluates a program's support of students in the areas of library resources, academic services, counseling services, health services, disability services, and financial aid services. The agency provided extremely limited documentation to demonstrate the consistent application of its student support services standards. Specifically, the agency only provided documentation of the applicable self-study sections and team report for one PT program, and that program does not appear to offer distance education. Although the documentation demonstrates the program addressed the self-study in the areas related to student support services and it was reviewed by the site team, the lack of a comprehensive review by the agency (to include CAPTE decision letter) in this area, as well as the documentation submission for only one program, does not demonstrate that the agency conducts reviews consistently and enforces its standards. Therefore, the agency must provide additional documentation to demonstrate systematic implementation of its student support services standards.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation (in Sections 602.16(a)(1)(iii) and (vii)) to demonstrate systematic implementation of its student support services standards, as well as documentation regarding the review of such information by the CAPTE board.



602.16(a)(1)(vii) Student Support Services

(a)(1)(vii) Recruiting and admissions practices, academic calendars, catalogs, publications, grading, and advertising.


The agency has clear and specific expectations regarding recruiting and admissions contained in Sections 5 & 8 of its standards and required elements for both the PT and PTA programs, as well as within the agency's integrity rules. The agency evaluates its programs for the accuracy and comprehensiveness of the information provided to prospective students and the public. Programs are required to provide information about academic calendars, grading policies, financial aid, the program’s accreditation status, the process to register a complaint with CAPTE, and outcome information, to prospective and enrolled students The agency provided extremely limited documentation to demonstrate the consistent application of its recruiting and admissions standards. Specifically, the agency only provided documentation of the applicable self-study section and team report for one PTA program, as well as the related exhibits from the program. Although the documentation demonstrates the program addressed the self-study in the areas related to recruiting and admissions and it was reviewed by the site team, the lack of a comprehensive review by the agency (to include CAPTE decision letter) in this area, as well as the documentation submission for only one program, does not demonstrate that the agency conducts reviews consistently and enforces its standards. Therefore, the agency must provide additional documentation to demonstrate systematic implementation of its recruiting and admissions standards.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation (in Section 602.16(a)(1)(iii) and this section) to demonstrate systematic implementation of its recruiting and admissions standards, as well as documentation regarding the review of such information by the CAPTE board.



602.16(a)(1)(ix) Program Length

(a)(1)(ix) Record of student complaints received by, or available to, the agency.


The agency has clear and specific expectations regarding student complaints contained in Sections 3 & 5 of its standards and required elements for both the PT and PTA programs. The agency's standards are sufficiently specific and require programs to have a complaint policy and make it readily available. Programs are required to maintain a written record of all complaints and their disposition. The agency provided extremely limited documentation to demonstrate the consistent application of its student complaints standards. Specifically, the agency only provided documentation of the applicable self-study sections and team report for one PTA program. Although the documentation demonstrates the program addressed the self-study in the areas related to student complaints and it was reviewed by the site team, the lack of a comprehensive review by the agency (to include CAPTE decision letter) in this area, as well as the documentation submission for only one program, does not demonstrate that the agency conducts reviews consistently and enforces its standards. Therefore, the agency must provide additional documentation to demonstrate systematic implementation of its student complaints standards.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation (in Section 602.16(a)(1)(iii) and this section) to demonstrate systematic implementation of its student complaints standards, as well as documentation regarding the review of such information by the CAPTE board.



602.19(b) Monitoring

(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 ยง602.16(f). This provision does not require institutions or programs to provide annual reports on each specific accreditation criterion.


The agency uses its annual report as its primary tool for monitoring the continued compliance of programs with the agency's standards. The agency also uses compliance reports, semi-annual reports of licensure pass rates, focused visits, complaints, and information from other sources to monitor compliance of programs. The agency stated that all programs must submit an annual report, which includes the reporting of student achievement measures and fiscal information, as well as changes to many other areas covered by the agency's standards. In the third and sixth years of a 10-year accreditation grant (or second year of an initial five-year cycle), the program must complete an extended version of the annual report to address additional standards and evaluative criteria. The agency also described its process to review the annual report provided by each program, to include the actions it could take as the result of its monitoring efforts. The agency provided an example letter to a program and a compliance report to demonstrate review and action taken as a result of the review of the annual report, however the submission of one example does not demonstrate consistent implementation. In addition, the agency provided a blank copy of its annual report and the continued compliance section, and therefore did not demonstrate that it collects key data and indicators, including fiscal information and measures of student achievement, to enable the agency to analyze and identify problems with a program's continued compliance with agency standards. The agency stated that it uses information from other sources to monitor compliance of programs, and provided documentation on the types of information sources and how the information is used in assessing continued compliance. The agency also provided documentation of use of its complaint process as a monitoring mechanism. The agency stated that it also uses semi-annual reports of licensure pass rates, and focused and/or unannounced site visits as part of its monitoring mechanism, but did not provide any documentation of the use of these mechanisms.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided comprehensive and additional documentation of all monitoring mechanisms used to the review the continued compliance of programs. Specifically, the agency provided additional information and documentation to demonstrate consistent review and action taken as a result of the review of the annual report. The agency provided completed copies of its annual report to demonstrate that it collects key data and indicators, including fiscal information and measures of student achievement, to enable the agency to analyze and identify problems with a program's continued compliance with agency standards. The agency also provided additional information and documentation on the use of semi-annual reports of licensure pass rates, and focused and/or unannounced site visits. The agency provided documentation that the Federation of State Boards of Physical Therapy provides CAPTE with licensure pass rates twice a year to monitor licensure pass rates. As the data can be old when reviewed, the agency will request additional and current information and documentation on licensure pass rates prior to taking further action, should the provided data fail to meet agency benchmarks. The agency also provided documentation of its use of a focused visit to collect additional information to assist CAPTE to make an appropriate decision about the status of the program, as part of its monitoring mechanism.



602.20(a) Enforcement Timelines

(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.


This criterion requires that an agency either initiate immediate adverse action or allow a program a time period, not to exceed two years, to come into compliance with its standards and requirements, when the agency's review of a program under any standard indicates that the program is not in compliance with that standard. The agency has written policy within Section 4.5(c)(3) of its rules of practice and procedure that provides a time period of no more than two years to return to compliance, but it does not state that the agency must either initiate immediate adverse action or allow such a time period. Specifically, Section 4.5(c)(3) states "If a Compliance Report is required, the Summary of Action includes the following notice: TWO YEAR LIMITATION ON BEING OUT OF COMPLIANCE CAPTE’s recognition by the United States Department of Education requires a limitation of two years for programs to be out of compliance with a required element [34 CFR 602.20(a)(2)(iii)]." This policy appears to assume the program has been granted a time period to return to compliance without any indication that CAPTE either contemplated an adverse action or has the authority under the rules of practice and procedure to do so. In addition, the agency's policies and procedures appear to require the use of a probationary status prior to an adverse action. Sections 4.5(c)(3) and 8.26 of its rules of practice and procedure list placing a program on probationary accreditation as the action directed should a program fail to make progress toward compliance or be out of compliance for 18 months. It appears the first time that an adverse action is an option to CAPTE is only after a program were noncompliant for two years, based on those sections as well as Section 8.16(c)(2) of its rules of practice and procedure. Based on the example provided in Section 602.19(b) (Exhibit "Monitor 1 Example"), the agency appears to implement the enforcement time period at the point the agency finds the program out of compliance with a standard, which meets the requirements of this section. However, the agency did not provide any other documentation (agency decision letters, etc.) that it has implemented its policies and meets the requirements of this section, to include initiating adverse action and enforcing a time period to return to compliance.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided information and documentation of the revision to its policies to meet the requirements of this section. The agency stated that since the policy revision, it has not had the opportunity to implement it. However, the agency did not provide information or documentation about the implementation of its previous policy in this area, nor did it indicate that it has never taken an adverse action against a program. The agency provided two comprehensive examples in Section 602.20(b), but neither of those included an adverse action nor enforcement of timeframes required by this section to demonstrate compliance.



602.20(b) Enforcement Action

(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 has a written policy within Section 8.16 of its rules of practice and procedure that meets the requirements of this section, and that makes clear the circumstances under which a good cause extension would be granted. The policy limits a good cause extension to two years. The agency did not provide any examples of agency decision letters for programs granted good cause extensions, nor the review of programs at the end of the extensions, to demonstrate implementation of its enforcement policy and compliance with this section. In Section 602.19(b), the agency provided an example (exhibit "Monitor 1 Example") of a program placed on probationary status and that was able to return to compliance within the time period provided by the agency, but not implementation of its good cause policy.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided two examples of its use of good cause extensions. However, it is not clear in those two examples that CAPTE specifically reviewed each program for a good cause extension under its rules nor that each program was informed that it was granted a good cause extension. For example 1, the program was first found out of compliance in November 2013 (page 53). In the November 2015 commission decision letter (page 916), the agency notified the program that it had continued deficiencies and must resolve the deficiencies by March 2016, but there was no indication of the grant of a good cause extension. In the May 2016 commission decision letter (page 934), the agency notified the program that it has resolved its deficiencies based on a compliance report. Example 2 provided the same documentation as example 1 - notification of out of compliance in November 2012 (page 2); notification of continued deficiencies in November 2104, with no indication of a good cause extension (page 198); and resolution of all deficiencies in November 2016 (page 225). The agency must clearly communicate to a program whether it has been granted an extension for good cause or not, if it does not take immediate adverse action as required by this criterion.



Part III: Third Party Comments


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