Commission On Collegiate Nursing Education 06/20/2017 05/12/2017 Final Review Renewal Petition

U.S. Department of Education

Staff Report

to the

Senior Department Offical

on

Recognition Compliance Issues


Recommendation Page



  1. Commission On Collegiate Nursing Education
  2. Renewal Petition
  3. The accreditation of nursing education programs in the United States, at the baccalaureate, masters and doctoral degree levels, including programs offering distance education.
  4. 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. June 20, 2017
  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. 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. 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

602.12(b) Expansion of Scope

(b) A recognized agency seeking an expansion of its scope of recognition must demonstrate that it has granted accreditation or preaccreditation covering the range of the specific degrees, certificates, institutions, and programs for which it seeks the expansion of scope.

(NOTE: Only recognized agencies seeking an expansion of scope need to respond.)


The agency is seeking an expansion of scope, per the letter of intent submitted to the Department October 2014 (exhibit 35), to include certificate programs in nursing, in which the agency has been accrediting such programs for the past three years. To date, the agency has granted accreditation to 129 certificate programs, in which a list of these programs has been provided (in addition to the web links included in the narrative) as evidence. The agency standards and procedures have been updated to reflect the inclusion of certificate programs demonstrating adequate inclusion of these programs as part of the agency's routine accrediting functions. Certificate programs are evaluated in conjunction with other nursing programs pursuing accreditation and do not receive a separate on-site evaluation. The agency has also provided exhibits 4, 33 and 34 as evidence of full cycle reviews of the existing programs within their scope of recognition as well as the certificate programs. Documentation provided to demonstrate the full cycle reviews include self-study documents from the program and Board accreditation action letters. It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. None of the documentation to demonstrate the full cycle of review displays the date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for and related to the same program. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency attests and provided evidence (exhibits 1 and 2) of full cycles of review for certificate programs, which includes the Institution identifier, full date of the on-site review, agency/program documents, correspondence, Board decision letters, and the accreditation effective dates to indicate that the documents provided are from and related to the same program. While the agency still illustrates the non-compliance practices of retroactive accreditation as evidenced in the documentation provided, which included the decision making body's decision during the September 20-26, 2016 meeting being backdated to the first day of the on-site visit of February 22, 2016 as the effective date of the program's accreditation, Department staff has been able to determine that CCNE has adequate standards and the capability to accredit certification 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 fall within the boundaries of the agency’s current scope of recognition. Department staff observed an on-site review of the agency's evaluation of certificate programs in nursing. Therefore, the Department staff recommends the approval of the agency's request for an expansion of scope.



602.15(a)(1) Staffing/Financial Resources

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--

(1) Adequate administrative staff and financial resources to carry out its accrediting responsibilities;


The agency, under the arm of the American Association of Colleges of Nursing with shared agreements for administrative and technical support, demonstrates it has adequate staff to carry out the accrediting responsibilities through the employment of elven full-time staff to manage the accreditation activities for its 1,567 accredited programs, which includes 129 certificate programs. The staff includes an Executive Director, two Directors of Accreditation Services, an Assistant Director, a Database Manager, two Accreditation Managers, three Accreditation Coordinators, and an Administrative Assistant (exhibits 7 and 8). Position descriptions for the aforementioned staff are contained in the internal operating manual, however, the resumes/curriculum vitae's of the staff were not provided in order for Department staff to assess whether their qualifications meet the duties of their outlined positions (exhibits 2 and 5). No complaints have been received by the Department challenging the adequacy of the agency's staff. The agency policies and procedures outline accreditation fees and costs and documentation demonstrating the three year fee structure (2, 5, and 6). The agency has provided financial audit reports for FY 2015 and FY 2016 which were deemed sufficient and appropriate by the auditors (exhibits 11 and 12). Lastly, the agency provided a financial statement and the 2017 budget a to indicate adequate operating revenue from fees and cost collected along with the financial management guidelines for investments of the agency as evidence (exhibits 9, 10 and 13).


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional information and documentation to address the previous concerns. Specifically, the agency response includes position descriptions (exhibit 19) and resumes (exhibit 20) of agency staff. The additional documentation demonstrates that the agency has qualified individuals to fulfill agency operations meeting the requirements of the criteria.



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;


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.



602.15(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 provides a definition of conflicts of interest and recusals throughout its bylaws, policies, procedures and orientation materials for committees, evaluators, and decision making bodies (exhibits 2, 5, 15, 19, 22, 23 and 36). The agency considers conflicts of interest for these entities to include, but not limited to, their current or former employment by the institution whose program is being evaluated; current employment in close proximity to or that is in direct competition with the institution whose program is being evaluated; attended the institution whose program is being evaluated; has a personal interest in a program; concurrently serve on the Board of Directors of AACN or decision-making body of another national nursing accrediting organization; and/or consultant for a baccalaureate, graduate, or residency program in nursing within the agency's scope of accreditation review. The agency's Board, committee members and site evaluators are expected to recognize potential conflicts of interest and recuse themselves from deliberations concerning the above. However, the agency did not provide evidence of recusals of Board and hearing committee members or indicate how such recusals were handled as evidence. Adhering to the new provisions included in the Higher Education Opportunities Act (2008), the agency revised their procedures which states that "membership of the Hearing Committee may not include a Board, committee, advisory group, or evaluation team member who was involved in the review of the program leading to the adverse action" (exhibit 2). The agency provided electronic questionnaires sent to on-site evaluators to identify conflicts of interest, and committee and Board member emails requesting conflicts to demonstrate adherence to the stated conflict of interest definitions (36-40, 44, 59, and 60). However, the agency has not provided signed conflict of interest forms for the Board members, hearing committee members, administrative staff, on-site evaluators and other accreditation committees attesting that they have read and understand the agencies conflict of interest policy. The electronic information provided has critical information redacted prohibiting the analyst to authenticate its contents.


Analyst Remarks to Response:

The agency provided documentation of signed conflict of interest forms for the Board members, hearing committee members, administrative staff; a sample of site evaluators and other accreditation committee members attesting that they have read and understand the agencies conflict of interest policy. The agency also provided a Board Meeting Agenda Excerpt demonstrating the process described in the agency narrative response for members that declare a conflict and recuse themselves from a review before each meeting. The New Board Member Orientation Agenda was also included demonstrating the review of conflicts of interest with new board members prior to participation in a full meeting.



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 Bylaws states that one of the goals of the agency is to ensure nursing education program outcomes are in accordance with the expectations of the nursing profession (exhibit 19). The agency accreditation standards states that a nursing program evaluation consists of a review of the program's mission, goals, expected outcomes, and assessment of program performance with evidence demonstrating the use of available resources, programs, and administration for assessing student achievement. Specifically, Standard IV and its key elements requires a review of various aspects of student achievement including that all levels (baccalaureate, master's, doctoral, and certificate) of the nursing program must demonstrate program effectiveness through program completion rates of 70%; licensure and certification pass rates of 80%; employment rates of 70%; and additional defined program outcomes, which may include student learning outcomes, alumni achievement, and employer satisfaction data (exhibit 1). Additionally, the nursing program's completion rates, NCLEX-RN® (licensure) and certification examination pass rates, and employment rates are required to be tracked for three years per agency guidance (exhibits 41). The agency's completion, licensure/certification, and employment rates are comparable to other nursing accreditors. The agency requires all nursing programs seeking accreditation, including programs offered via distance education or through a consortium, to comply with the aforementioned student achievement standards. The agency's on-site evaluation teams assess nursing programs compliance with the student achievement standard requirements through the examination of the data provided by the programs self-study, explanation of how the data were collected, and what the data shows in terms of program effectiveness. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements for student achievement which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key elements associated with student achievement (standard IV; key elements IV B-E), an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibits 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for and related to the same program. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decisions regarding several programs compliance with its student achievement standards (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its student achievement standards, which is the reason for Department staff's decision to find the agency compliant at this time. However, the agency's documentation has revealed addition concerns. Upon further review of exhibit 03 with the agency updates, Department staff discovered full accreditation was extended to a program with compliance concerns related to student achievement. In particular, exhibit 03 includes a letter to the program from the Accreditation Review Committee (ARC) dated March 30, 2015 demonstrating that the program is non-compliant with Key Element IV-C of Standard IV. This letter explicitly states that the program must "demonstrate that certification pass rates demonstrates program effectiveness, specifically, the program must demonstrate that it is collecting pass rate data;" and provides April 14, 2015 as the response date for the program to address the compliance concern, prior to the Board meeting April 28-May 1, 2015. The program response to the non-compliant area was provided on April 7, 2015 to the agency prior to the start of the April 28 Board meeting. However, the Board decision letter to the program dated May 28, 2015 states that all four accreditation standards have been met; yet, the same paragraph states the Board determined a compliance concern with Key Element IV-C of Standard IV. The letter further identifies the compliance concern as the same concern identified in the aforementioned March 30, 2015 letter sent to the program from the ARC, which was responded to by the program on April 7, 2015, per the updated documentation. The letter then allows the program until June 1, 2016 to come into compliance through the submission of a compliance report; while granting the program retroactive accreditation dating back to the first day of the on-site evaluation until June 2020. The agency is not being found non-compliant at this time, as it may be able to explain these apparent disparities, including at NACIQI. 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. As noted previously, documentation provided by the agency still demonstrates the practice of awarding accreditation retroactive to the first day of the on-site evaluation. Department staff addresses this issue in section §602.23 (a) which includes the Department of Education's expectations regarding the accreditation effective date. In addition, the agency is being found non-compliant in that section for its retroactive accreditation practice, even though agency documentation evidencing this practice is used in other sections of the agencies petition.



602.16(a)(1)(ii) Curricula

(a)(1)(ii) Curricula.


The agency accreditation standard III states that curricula must be developed in accordance with the program's mission, goals, and expected student outcomes; reflect professional nursing standards and guidelines including the needs and expectations of the community; and demonstrate congruence between teaching-learning practices and expected student outcomes (exhibit 1). Specifically, Standard III and its key elements require a review of various aspects of the nursing curricula including that all program levels of the nursing program be logically structured to achieve expected student outcomes; demonstrate the curricula integrates nationally accepted professional nursing standards and guidelines; and the baccalaureate, master's program and doctoral program curricula are developed in accordance with the essentials for professional nursing practice for the American Association of Colleges of Nursing (exhibits 45-47). However, certificate programs are developed using professional nursing standards and guidelines relevant to that particular program, area or specialty. The agency requires all nursing programs seeking accreditation, including programs offered via distance education or through a consortium, to comply with the aforementioned curricula standards. The agency's on-site evaluation teams assess nursing programs compliance with the curricula standard requirements through the examination of the data provided by the programs self-study, observations/interviews with faculty and students including the review of catalogs, recruitment literature, handbooks, course syllabi, outlines and schedules, and documentation pertaining to the clinical experience. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements for curricula which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key elements associated with curricula (standard IIII; key elements III B-C), an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibits 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for the same program and related. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decision regarding several programs compliance with its curriculum standards (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its curriculum standards, which is the reason for the Department staff's decision to find the agency compliant at this time. As noted in 602.16(a)(i), the issue regarding CCNE's possible granting of accreditation with what appears to be deficiencies may be explained by the agency 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. As noted previously, the agency awards accreditation retroactive to the first day of the on-site evaluation. This non-compliant issue is addressed in detail in section §602.23(a), which includes the Department of Education's expectations regarding the accreditation effective date, even though agency documentation evidencing this practice is used in other sections of the agencies petition.



602.16(a)(1)(iii) Faculty

(a)(1)(iii) Faculty.


The agency accreditation standards address faculty in multiple areas, particularly standards I, II and IV, to demonstrate adherence to the criteria. Standard II states that faculty facilitates the achievement of the mission, goals, and expected program outcomes. The key elements of this standard requires nursing program faculty to have the education and experience to teach. The faculty must be in sufficient number and the program must provide a supportive environment for faculty. Standard I, Program quality: mission and governance, key elements require nursing units to identify expected faculty outcomes and institutional expectations; and involve faculty in the governance of the program. Finally, Standard IV, Program effectiveness: assessment and achievement of program outcomes, and its key element requires faculty outcomes to demonstrate program effectiveness (exhibit 1). The agency requires all nursing programs seeking accreditation, including programs offered via distance education or through a consortium, to comply with the aforementioned faculty standards. The agency's on-site evaluation teams assess nursing programs compliance with the faculty standard requirements through the examination of the data provided by the programs self-study, observations/interviews with faculty and students, faculty evaluations, development activities, handbooks and vitae's, along with institutional and program policies related to faculty. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements for faculty which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key elements associated with faculty, an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibits 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for the same program and related. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decisions regarding several programs compliance with its faculty standards (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its faculty standards, which is the reason for the Department staff's decision to find the agency compliant at this time. As noted in 602.16(a)(i), the issue regarding CCNE's possible granting accreditation with what appears to be deficiencies may be explained by the agency 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. Agency evidence still demonstrates the practice of awarding accreditation retroactive to the first day of the on-site evaluation. This non-compliance issue is addressed in detail under §602.23(a), which includes the Department of Education's expectation regarding the accreditation effective date, even though the agency documentation evidencing this practice is used in other sections of the agencies petition.



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

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


The agency accreditation standard relative to facilities, equipment, and supplies, standard II- program quality: institutional commitment and resources, states that the parent institution must demonstrate ongoing commitment, support, and resources to the program. Key elements of the standard require fiscal and physical resources to be sufficient for the program to fulfill its mission, goals, and expected outcomes; and a periodic review of the adequacy of resources. The agency’s standards ensure that it has a systematic process to review the facilities, equipment, and supplies at nursing programs (exhibit 1). The agency requires all nursing programs seeking accreditation, including programs offered via distance education or through a consortium, to comply with the aforementioned facilities, equipment, and supplies standards. The agency's on-site evaluation teams assess nursing programs compliance with the facilities, equipment, and supplies standard requirements through the examination of the data provided by the programs self-study, use and proposed modifications of space or facilities, and the availability and adequacy of the programs essential equipment and supplies. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements for facilities, equipment, and supplies which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key element associated with facilities, equipment, and supplies (standard II; key elements IIA), an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibit 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for the same program and related. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decisions regarding several programs compliance with its standards relative to this criterion (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its standards relative to this criterion, which is the reason for the Department staff's decision to find the agency compliant at this time. As noted in 602.16(a)(i), the issue regarding CCNE's possible granting accreditation with what appears to be deficiencies may be explained by the agency 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. Agency evidence still demonstrates the practice of awarding accreditation retroactive to the first day of the on-site evaluation. This non-compliance issue is addressed in detail under §602.23(a), which includes the Department of Education's expectation regarding the accreditation effective date, even though agency documentation evidencing this practice is used in other sections of the agencies petition.



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

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


The agency accreditation standard relative to fiscal and administrative capacity, standard II- program quality: institutional commitment and resources, states that the parent institution must demonstrate ongoing commitment, support, and resources to the program. A key element of the standard requires a periodic review of the adequacy of resources, including sufficiency of fiscal and physical resources for the program. The chief nurse administrator must meet the agency’s academic and experience requirements and have administrative authority and leadership within the nursing unit. The agency’s standards ensure it has a systematic process to review the fiscal and administrative capacity of nursing programs (exhibit 1). The agency requires all nursing programs seeking accreditation, including programs offered via distance education or through a consortium, to comply with the aforementioned fiscal and administrative capacity standard and key element. The agency's on-site evaluation teams assess nursing programs compliance with the fiscal and administrative capacity standard requirements through the examination of the data provided by the programs self-study, strategic planning documents, annual reports, and financial evidence of institutional commitment and adequacy of program resources. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements for fiscal and administrative capacity which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key element associated with fiscal and administrative capacity (standard II; key elements II A and C), an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibit 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for the same program and related. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decisions regarding several programs compliance with its standards relative to this criterion (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its standards relative to this criterion, which is the reason for the Department staff's decision to find the agency compliant at this time. As noted in 602.16(a)(i), the issue regarding CCNE's possible granting accreditation with what appears to be deficiencies may be explained by the agency 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. Agency evidence still demonstrates the practice of awarding accreditation retroactive to the first day of the on-site evaluation. This non-compliance issue is addressed in detail under §602.23(a), which includes the Department of Education's expectation regarding the accreditation effective date, even though agency documentation evidencing this practice is used in other sections of the agencies petition.



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

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


The agency accreditation standard relative to student support services, standard II-program quality: institutional commitment and resources, states that the parent institution must demonstrate ongoing commitment, support, and resources to the program. Key elements for the standard requires academic support services, in which the agency's standards glossary defines as services available to the nursing program that facilitate faculty and students in any teaching/learning modality, including distance education, be sufficient and evaluated on a regular basis to meet program and student needs. The agency’s standards ensure it has a systematic process to review the student support available for nursing programs (exhibit 1). T he agency's on-site evaluation teams assess nursing programs compliance with the student support services standard requirements through the examination of the data provided by the programs self-study, observation/interviews with faculty, students and support services personnel, policies for academic advising and career counseling, orientation materials, student handbooks, library, technology, and posted information for students. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements for student support services which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key element associated with student support services (standard II; key elements II B), an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibit 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for the same program and related. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. I n accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decisions regarding several programs compliance with its standards relative to this criterion (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its standards relative to this criterion, which is the reason for the Department staff's decision to find the agency compliant at this time. As noted previously, the issue regarding CCNE's possible granting accreditation with what appears to be deficiencies may be explained by the agency 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. Agency evidence still includes the practice of awarding accreditation retroactive to the first day of the on-site evaluation. This non-compliance issue is addressed in detail under §602.23(a), which includes the Department of Education's expectation regarding the accreditation effective date used by accrediting agencies even though agency documentation evidencing this practice is used in other sections of the agencies petition.



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

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


The agency accreditation standards address recruiting and other practices in multiple areas, particularly standards I and III, to demonstrate adherence to the criteria. Standard I, Program quality: mission and governance, key elements requires documents and publications to be accurate; notifications to constituents of changes to documents/publications; congruence between parent institution and program on academic policies; and involvement of faculty in the governance of the program. Finally, Standard III, Program quality: curriculum and teaching-learning practices, which addresses grading, requires student performance be evaluated by the faculty and reflect achievement of expected student outcomes (exhibit 1). The agency also provides guidance to programs to ensure Department requirements are met when preparing for an on-site evaluation (exhibit 41). The agency requires all nursing programs seeking accreditation, including programs offered via distance education or through a consortium, to comply with the aforementioned recruiting and other practices standards. The agency's on-site evaluation teams assess nursing programs compliance with recruiting and other practices standard requirements through the examination of the data provided by the programs self-study, academic calendars, recruitment, admission and grading policies, degree completion requirements, program advertising, promotional materials, handbooks and related institutional documents. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements for recruiting and other practices which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key elements associated with recruiting and other practices, an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibit 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for the same program and related. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decisions regarding several programs compliance with its standards relative to this criterion (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its standards relative to this criterion, which is the reason for the Department staff's decision to find the agency compliant at this time. As noted previously, the issue regarding CCNE's possible granting accreditation with what appears to be deficiencies may be explained by the agency 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. Agency evidence still demonstrates the practice of awarding accreditation retroactive to the first day of the on-site evaluation. This non-compliance issue is addressed in detail under §602.23(a), which includes the Department of Education's expectation regarding the accreditation effective, even though agency documentation evidencing this practice is used in other sections of the agencies petition.



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

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


The agency accreditation standard relative to student complaints, standard IV, Program effectiveness: assessment and achievement of program outcomes, states data on program effectiveness are used to foster ongoing program improvement. Specifically, the key elements require programs to review and have in place defined formal complaint policies; and analyze complaint data to foster program improvement. The agency’s standards ensure it has a systematic process to review the programs complaint process and procedures (exhibit 1). The agency requires all nursing programs seeking accreditation, including programs offered via distance education or through a consortium, to comply with the aforementioned student complaints standards. The agency's on-site evaluation teams assess nursing programs compliance with the student complaint standard requirements through the examination of the data provided by the programs self-study, interviews with faculty, students and administrators, formal complaint policies, records of formal complaints for the last three years, and actions taken on the complaints. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements of student complaints which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key element associated with student complaints (standard IV; key elements II G and H), an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibit 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for the same program and related. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decisions regarding several programs compliance with its standards relative to this criterion (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its standards relative to this criterion, which is the reason for the Department staff's decision to find the agency compliant at this time. As noted previously, the issue regarding CCNE's possible granting accreditation with what appears to be deficiencies may be explained by the agency 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. Agency evidence still demonstrates the practice of awarding accreditation retroactive to the first day of the on-site evaluation. This non-compliance issue is addressed in detail under §602.23(a), which includes the Department of Education's expectation regarding the accreditation effective date, even though agency documentation evidencing this practice is used in other sections of the agencies petition.



602.17(a) Mission & Objectives


(a) Evaluates whether an institution or program--

(1) Maintains clearly specified educational objectives that are consistent with its mission and appropriate in light of the degrees or certificates awarded;

(2) Is successful in achieving its stated objectives; and

(3) Maintains degree and certificate requirements that at least conform to commonly accepted standards;


The agency Bylaws, standards, and procedures articulate the factors used to determine defined objectives of the nursing program along with the accreditation purpose (exhibits 19, 1, and 2). The agency standards also state that on-site evaluations are to consist of an assessment of performance and review of effective utilization of resources in achieving the program's mission, goals, and expected outcomes. Multiple standards, particularly standards I, III, and IV demonstrate adherence to the criteria. Specifically, standard I and its key elements pertaining to program quality: mission and governance, which require the program's mission, goals and outcomes be congruent with the parent institution, reflect professional nursing standards and guidelines, and consider the needs of the community; standard III and its key elements for program quality: curriculum and teaching-learning practices, requires evaluation of student performance by faculty; and standard IV, program effectiveness: assessment and achievement of program outcomes, requires the program to provide program completion, licensure/certification, and employment rates, in addition to other program outcomes. The agency requires all nursing programs seeking accreditation, including programs offered via distance education or through a consortium, to comply with agency standards and requirements. Lastly, the agency's evaluation of the nursing programs, housed in regionally and nationally accredited institutions, includes a review of degree and certificate programs in conjunction with professional nursing standards and guidelines to ensure a foundation for professional nursing behaviors is obtained by their graduates. The agency's on-site evaluation teams assess nursing programs compliance with stated mission and objectives through the examination of the data provided by the programs self-study, accreditation reports, and evaluation of qualitative and quantitative student learning outcomes. The agency provided evidence of a full cycle of review to demonstrate the review of the aforementioned requirements for program mission and objectives which included the following: agency notification of an upcoming review to the program; agency notification to the program of the formulation of an on-site evaluation team, which includes a request for conflicts of Interests from the program with the proposed on-site evaluation team members; screen shots of the electronic database the program inputs general information in about the program, which includes distance education for agency review; a self-study from the program, which includes an assessment of each agency standard and key element associated with the programs mission and objectives, an agenda of the on-site evaluation; a notification to the program of next steps after the on-site evaluation; site-evaluation report for the program identifying compliance and concerns for each standard and key element; notification to the program of findings; a response to the report from the program; invitation to and notification of the accreditation review committee meeting on the report; and the Board's decision letter to the program (exhibit 4, 33, 34 and 44). It is important to note, the agency’s practice of redacting information is problematic and hinders Department staff’s analysis and compliance determination. Many of the documents to demonstrate the full cycle of review displays no complete date of the action. In addition, the name of the institution or program is also redacted. The agency must provide an identifier in order for Department staff to ascertain if the accreditation documents (site visit reports, self-studies, decision letters and other related accreditation evaluation documents) are actually for the same program and related. This also hinders Department staff's analysis of the documentation to ensure agency deadlines outlined in its policies, procedures and notification letters to the program have been met, including whether all federal timelines have been met. The names on the evaluator list were redacted; however, the role of the individuals were displayed which enabled Department staff to determine that evaluations teams are of the proper composition. As noted previously, Department staff would expect the names of the agency’s decision making bodies be displayed on documentation as that information is readily available to the public. It is also important to note, the year of the Board meeting and the effective date of the accreditation decision within exhibit 44 part 2 demonstrates the Department's concern and determination of the agency's non-compliance with the use of retroactive accreditation dates identified in the Department's letter to the agency. In accordance with 34 CFR 602.31 (f), “the agency may redact information that would identify individuals or institutions that is not essential to the Departments review of the agency”. However, the requested information is essential to the Departments review. Therefore, the agency must provide this needed information (complete dates on accreditation documents and a program identifier) before a compliance determination can be made.


Analyst Remarks to Response:

The agency provided updated full cycles of review with the inclusion of a program identifier and the removal of redacted dates for selected documents to demonstrate its review, assessment, and decisions regarding several programs compliance with its standards relative to this criterion (exhibits 01-03). The identifiers enable Department staff to ascertain the relationship between the site visit report, self-study, and decision letters as being associated with the same program. Department staff is able to determine that CCNE applies its standards relative to this criterion, which is the reason for Department staff's decision to find the agency compliant at this time. As noted previously, the issue regarding CCNE's possible granting accreditation with what appears to be deficiencies may be explained by the agency 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. Agency evidence still demonstrates the practice of awarding accreditation retroactive to the first day of the on-site evaluation. This non-compliance issue is addressed in detail under 602.23(a), which includes the Department of Education's expectation regarding the accreditation effective date, even though agency documentation evidencing this practice is used in other sections of the agencies petition.



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 utilizes five monitoring performance reports between comprehensive program reviews to demonstrate adequate monitoring of the nursing programs. These reports include the continuous improvement progress reports (CIPR), required at the mid-point term of accreditation; special reports, required if a program has not met an agency standard at the time of initial or continued accreditation; compliance reports, required if the program has a compliance concern for one or more key elements at the time of initial or continued accreditation; annual reports, required for providing yearly statistical data and other information about the parent institution, program(s), faculty, and students; and substantive change notifications, required for any substantive change affecting the nursing program (exhibit 2). The agency's report review committee reviews (RRC) 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 annual report aggregate data provided by the program through a reporting instrument is reviewed and collected by the RRC to satisfy the agency's annual reporting requirements for the American Association of Colleges of Nursing in areas of headcount /enrollment, licensure pass rates, etc. (exhibits 52, 53, 57, 58 and 60). The agency then provided the RRC orientation agenda to demonstrate the training provided to committee members for this role (exhibit 23). The nursing program is also required to notify the agency, through a request, of substantive changes that affect the accreditation of the program. This request is required in writing 90 days prior to implementation or occurrence of the change including the nature/scope of the substantive change and how the change will affect the program's compliance with agency standards. These requests are reviewed by the substantive change advisory group of the agency and their recommendations are provided to the executive committee of the Board or the full Board for action on the request. The agency is not required to demonstrate compliance with the substantive change criteria (34 CFR 602.22). Based upon the information provided in the agency’s narrative, it appears the substantive change advisory group is involved in the agency’s accreditation/program approval process through its review of substantive change request. The agency must provide more information regarding the substantive change advisory group membership, its function, training and qualifications for its members. The agency provided a full cycle of review, CIPR information sent to the program, a completed CIPR report, a special report, and a substantive change notification as evidence. The agency has not provided evidence of a compliance report and a substantive change request, if a substantive change request has been requested during this review period. Also, the months of the aforementioned documents are blacked out, preventing Department staff from determining if any of the enforcement timelines required in 602.20 (a) have been exceeded.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided the 2017 updated Procedures and Internal Operating Manual (exhibits 17 and 22) with the inclusion of the Substantive Change Review Committee (SCRC) function, composition, membership orientation and training received along with resumes of the current members demonstrating their qualifications to satisfy the staff concerns in this area (exhibit 16). The agency also provided additional and updated evidence requested by staff with the removal of redacted dates from selected documents so a compliance determination could be made (exhibits 01-06). Upon further review, the updated documents provided support the current protocols the agency has in place to monitor the nursing education program. As noted in 602.16(a)(i), the issue regarding CCNE's granting accreditation with what appears to be deficiencies may be explained by the agency 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.



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.


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.



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 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(a) Public Information

(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).