Southern Association Of Colleges and Schools 06/20/2017 05/19/2017 Final Review Renewal Petition

U.S. Department of Education

Staff Report

to the

Senior Department Offical

on

Recognition Compliance Issues


Recommendation Page



  1. Southern Association Of Colleges and Schools
  2. Renewal Petition
  3. The accreditation and preaccreditation (“Candidate for Accreditation”) of degree-granting institutions of higher education in Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Virginia, including the accreditation of programs offered via distance and correspondence education within these institutions. This recognition extends to the SACSCOC Board of Trustees and the Appeals Committee of the College Delegate Assembly on cases of initial candidacy or initial accreditation and for continued accreditation or candidacy.
  4. The accreditation and preaccreditation (“Candidate for Accreditation”) of degree-granting institutions of higher education in Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Virginia, including the accreditation of educational programs offered via distance and correspondence education within these institutions. The accreditation status of these institutions and their recognition extends to the SACSCOC Board of Trustees and the Appeals Committee of the College Delegate Assembly on cases of initial candidacy or initial accreditation and for continued accreditation or candidacy.
  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.
  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 provide additional explanation and documentation for the missing resumes and Board of Trustee members on the roster. [§602.15(a)(2)] -- The agency does not meet the requirements of this section of the criteria. The agency needs to provide signed conflict of interest forms of appeals committee and evaluation team members (7-10 of each). [§602.15(a)(6)] -- The agency does not meet the requirements of this section of the criteria. The agency needs to provide the documents associated with the full cycle of review of the substantive change proposal provided as evidence to demonstrate compliance. The documents should include the agency review of the proposal, recommendations, and decision letters from the decision making bodies. [§602.22(a)(1)]

Executive Summary



Part I: General Information About The Agency

The Southern Association of Colleges and Schools, Commission on Colleges (SACS or agency), is a regional institutional accreditor. SACS accredits or preaccredits (“Candidate for Accreditation”) 794 degree-granting institutions of higher education in Alabama, Florida, Georgia, Kentucky, Louisiana, Mississippi, North Carolina, South Carolina, Tennessee, Texas, and Virginia, including distance and correspondence education programs offered at those institutions. Over 98% of the 794 institutions accredited by the Commission rely on the agency’s continued recognition by the U.S. Department of Education for access to Title IV, HEA programs. During this recognition period, the Department received 3 third-party comments and 2 complaints.

Recognition History

SACS appeared on the initial list of nationally recognized accrediting agencies published by the U.S. Office of Education in 1952. The agency’s recognition has been periodically reviewed and continued recognition has been granted after each review. The agency's last review for continued recognition was in 2012, which resulted in the agency having to submit a compliance report regarding four outstanding issues. The agency's compliance report submission was reviewed in 2014, which resulted in the agency’s continued recognition for a period of 3 years. The agency's review for continued recognition is the subject of this analysis.


Part II: Summary Of Findings

602.10 Link to Federal programs

The agency must demonstrate that--

(a) If the agency accredits institutions of higher education, its accreditation is a required element in enabling at least one of those institutions to establish eligibility to participate in HEA programs; or

(b) If the agency accredits institutions of higher education or higher education programs, or both, its accreditation is a required element in enabling at least one of those entities to establish eligibility to participate in non-HEA Federal programs.


The agency has attested that there have been no changes to the policies or practices since its last review before the NACIQI, however, exhibit 57 has been provided without a narrative explaining its relevance to the criteria.


Analyst Remarks to Response:

The agency explained that exhibit 57 is not relevant to the criteria and was submitted inadvertently. Thus, the agency attests that there have been no changes to their policies or practices since its last review before the NACIQI for the criterion.



602.11 Geographic scope of accrediting activities.

The agency must demonstrate that its accrediting activities cover--

(a) A State, if the agency is part of a State government;

(b) A region of the United States that includes at least three States that are reasonably close to one another; or

(c) The United States.


The agency has attested that there have been no changes to the policies or practices since its last review before the NACIQI; however, the agency must address the technical changes to some of the words of the current scope in the ‘Requested Scope of Recognition’ section of the petition.


Analyst Remarks to Response:

The agency has explained the reasoning for the technical changes to its scope. The agency indicates that the modifications to the current scope of recognition serve as clarifying edits to the existing scope and identifies the authority already contained within its current scope of recognition more clearly. The agency is not requesting an expansion of its current scope.



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 has provided a change in the current scope of recognition, however a reason for this change in scope has not been provided to Department staff.


Analyst Remarks to Response:

The agency has explained the reasoning for the technical changes to its scope. The agency indicates that the modifications to the current scope of recognition serve as clarifying edits to the existing scope and identifies the authority already contained within its current scope of recognition more clearly. The agency is not requesting an expansion of its current 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 provided an organizational chart of 52 staff (exhibit 1), position descriptions (exhibit 2), biographical sketches (exhibit 3) and orientation materials for senior level staff (exhibit 4), which provide accreditation support to approximately 800 institutions, to demonstrates it has adequate staff to carry out its accrediting responsibilities. However, the agency has not provided resumes and position descriptions for all staff participating in accreditation activities for Department staff to assess whether agency staff are qualified through education and experience to execute the accrediting responsibilities. The agency provided audit findings for FY 2015 and FY 2016 (exhibits 7-8) which demonstrate acceptable accounting practices, as noted in the auditor’s report. The agency provided budget breakdowns (exhibit 5) of dues, fees, and expenses collected for administration of accreditation activities exhibiting adequate financial resources and practices by the agency. The Department has received no complaints related to adequacy of the agency staff in fulfilling the accrediting responsibilities.


Analyst Remarks to Response:

The agency has provided additional documentation in response to the draft staff analysis. The agency attests that the documentation provided, including position descriptions, biographical sketches and curriculum vitae’s, are of all staff participating in and executing accreditation activities at the agency.



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 is comprised of the College Delegate Assembly, Appeals Committee, Board of Trustees, Executive Council and the Committees on Compliance and Reports as outlined in the Resource Manual for the Principles of Accreditation (exhibit 14), Handbook for Review Committees (exhibit 13), the Handbook for the Committees on Compliance and Reports (exhibit 25), and the Appeals Committee Procedures (exhibit 28). The responsibility for administering the accreditation process is vested in the off and on-site review committees, the committee on compliance and reports, executive council of the Board, and the Board of Trustees, who takes final action. The agency requires institutions seeking initial or renewed accreditation status to undergo layers of review. T he Board of Trustees consist of seventy-seven (77) members who make final decisions in determining institutional compliance with standards for initial or reaffirmation of accreditation (exhibits 11 and 25). The members of the Board of Trustees are elected by the College Delegate Assembly, which is comprised of one voting representative from each of the agency's approximately 800 accredited member institutions. The Board also includes two branches of review, the executive council and the compliance and reports committees, both comprised of Board of Trustee members. The agency has provided agendas and accompanying materials documenting the orientation and training of the decision-makers for the agency to ensure understanding of policies, procedures and standards while in their perspective roles (exhibits 17-26). The agency's scope of recognition includes the evaluation of distance education and correspondence education, which is also included in the training materials for the Board members (exhibit 31). However, the agency has not provided CVs for its Board of Trustees to demonstrate that the qualifications of the decision-makers to execute the roles and responsibilities outlined in the agency's policies and procedures are met. The agency’s institutional review teams consist of an off-site reaffirmation committee and an on-site review committee. The off-site reaffirmation committee is composed of a chair and evaluators for finance, institutional effectiveness, organization and administration, student support services, learning support services, and two or more evaluators for educational programs depending on the size and complexity of the institutions. The on-site review Committee is composed of a chair and evaluators in the areas of organization and governance, faculty, educational programs, and student support or library. The agency policies and procedures identify the aforementioned compositions of the off and on-site review committees demonstrating adherence to the requirements for the criteria, however, reaffirmation reports provided as evidence in the subsequent sections do not include site team members and their areas of expertise for analysis. The agency has also included standards and training materials demonstrating an extensive review of agency requirements, as well as the role of evaluators who will review the application of standards, policies, procedures, and requirements during off and on-site evaluations (exhibits 10-11 and 13-23). Exhibit 31 provides specific guidance and training on the review of distance and correspondence education which is provided to all participating in accreditation activities for the agency. An appeal's committee is also in place for institution’s requesting review of accreditation actions (exhibit 28). The appeals committee consists of twelve members who have served on the Commission's Board of Trustees which include eight chief executive officers, two faculty/academic personnel, and two public members. The members of the appeals committee are elected by the College Delegate Assembly, which is comprised of one voting representative from each of the agency's accredited member institutions. The appeals committee allows an applicant, candidate, and member institutions to appeal adverse decisions (exhibits 11 and 28). However, the agency has not provided CVs for appeals committee members to demonstrate the qualifications of these decision-makers to ensure the academic, administrator and public member requirements are met for the criteria.


Analyst Remarks to Response:

In response to the draft staff analysis the agency has provided additional documentation. In particular, the agency has provided biographical sketches, resumes, curriculum vitae's and a roster for the Appeals Committee members (exhibits E and analyst upload of exhibit 10). In addition, the agency provided biographical sketches, resumes, curriculum vitae's and a roster for some of the Board of Trustee members (exhibits D and analyst upload of exhibits 9 parts1-3). The agency attests that there are 77 Board of Trustee members; however the agency has not provided a roster and resumes for all 77 Board of Trustee members.



602.15(a)(3) Academic/Administrator Representatives

(3) Academic and administrative personnel on its evaluation, policy, and decision-making bodies, if the agency accredits institutions;


The agency's Handbooks for Review Committees (exhibit 13), Institutions Seeking Reaffirmation (exhibit 11),and Committees on Compliance and Reports (exhibit 25) along with the Resource Manual for the Principles of Accreditation (exhibit 14) outlines the requirements of the Board of Trustees for the agency. The Board is comprised of 77 members with 66 administrators and faculty from member institutions, and 11 public members, which meets the one seventh requirements for public member representation on the Board of Trustees. The Board of Trustee members also participate in the different layers of the peer review, including 13 members on the Executive Council and 64 members on Committees on Compliance and Reports demonstrating a balance of academic and administrative educators representing the Board, thus adhering to the criteria. The agency has provided rosters of the Board of Trustee members (exhibit 27), Executive Council (exhibit 12 and 35) and the Committees on Compliance and Reports (exhibit 34) to further demonstrate compliance with the criteria. The agency's written Appeals Procedures (exhibit 28) states the composition of the Appeals Committee, which shall consist of twelve persons elected by the College Delegate Assembly, which is comprised of one voting representative from each of the agency's approximately 800 accredited member institutions, and has served on the Commission's Board of Trustees. The members consist of eight chief executive officers, two faculty/academic personnel, and two public members, which is in adherence with the criteria. The agency has also included a roster of the Appeals Committee in section 602.15(a)(2) of the petition (exhibit 30). The agency outlines the roles, responsibilities and composition of the off and on-site evaluator teams within the Handbook for Review Committees (exhibit 13). These teams include evaluators in the areas of faculty, educational programs, learning or student support services, institutional effectiveness, and two additional evaluators for the Quality Enhancement Plan, submitted by the institution, specifically for on-site evaluations. The agency requires a minimum of seven members to serve on the site committees, in which academic and administrative evaluators are required, per the agency Handbook. Evidence of the off and on-site review teams are found in the rosters and training materials included in exhibits 12, 36, and 17-26. However, the agency has not provided reports that identify the composition of the visiting evaluators to demonstrate that the off and on-site teams include academic and administrative representatives. The agency site evaluators are housed in an evaluation registry which consists of individuals recommended by the chief executive officer of an institution. These individuals complete an evaluator Information form that includes the education and experience of the potential evaluator. Upon agency review, the individual is added to the evaluator registry.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional documentation to evidence compliance with the criteria. Specifically, the agency provided off and on-site reaffirmation evaluator rosters for Baylor College of Medicine, Durham Technical College, and University, which includes the area of expertise of the evaluator from the evaluator registry for the agency.



602.15(a)(5) Public Representatives

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


The agency describes within the Standing Rules of SACSCOC Board of Trustees policy and the Appeals Committee Procedures of the College Delegate Assembly that it is required to have eleven public representatives, defined as individuals who are not an employee, member of a governing board or coordinating board, or an owner/shareholder of an institution accredited by SACSCOC, on the Board of Trustees. Two public representatives are also included on the Appeals Committee, and one on the Executive Council, (exhibit 42 and 28), which demonstrates adherence to the criteria. Public representatives for the Board are selected through an election process, overseen by the Executive Council, who distributes guidelines and ballots for the election and re-election of these members every September to council members and state delegates (exhibits 43-44). However, the agency has not included its bylaws and safeguards that are in place to ensure the elected representatives continue to meet all of the aforementioned requirements during their tenor on the Board. Rosters of current Board of Trustees Committee members are evidenced in exhibits 27; along with a master list of candidates and nominations to the Board for public members (exhibits 47 and 48). The agency also provided two vitae’s and ballots of nominee’s for public representative (exhibits 45-46), however, inclusion of all public member resumes/curriculum vitae’s, demonstrating their qualifications outlined in the definition and requirements, have not been provided with the Board’s roster as evidence. The Appeals Committee public representatives selection process requires the SACSCOC Nominating Committee to review candidates that adhere to the federal definition of a public member and the Commission’s requirement of the individual to must have served as a member of the Board of Trustees, but not as a current Board member, prior to their selection and election by the College Delegate Assembly (exhibit 28). A roster of the Appeals Committee was submitted as evidence (exhibit 30); however the public members are not identified on the agency roster, nor are their resumes/curriculum vitae’s included for review.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional explanation and documentation. In particular, the agency provided additional explanation on their standing rules policy that demonstrates safeguards in place to ensure the public members meet agency and Department requirements for this role (exhibit 16H). The agency then provided rosters and resumes of the public members on the Appeals Committee and Board of Trustees demonstrating their inclusion and qualifications for this specified role (exhibits 14, 15, 7G and 8F). The agency also addressed the third party commenter's allegations about two public members, in which the agency attests are not true and reaffirms the agency definition and policies are enforced for all public members.



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's policy documents for ethical obligations of Board of Trustee members and evaluators, along with the appeals committee procedures, demonstrates there are controls in place at the agency to safeguard against conflicts of interest or the appearance of a conflict of interest by evaluators, staff and decision making bodies (exhibits 10, 26, and 28). Some examples of conflicts of interest for evaluators, staff and decision making bodies include, being employed within a state where the parent campus of the institution is located; has been a candidate for employment at the institution within the last ten years; is a graduate of the institution; is a stockholder or board member of the institution; and is a Board of Trustee member and has been invited to serve as chair or member of an evaluation committee scheduled to review the institution of another Board member. The agency policy also addresses conflict of interest and undue influence of an evaluator. The agency handbooks for institutions seeking reaffirmation and for review committees also identify procedures for conflicts of interest and recusals (exhibits 13 and 53). The agency has provided signed conflict of interest forms of an administrative staff member and Board of Trustee member included in the organizational chart and roster provided as evidence (exhibits 1, 27, 49 and 51). However, the signed conflict of interest form of the appeals committee member included as evidence (exhibit 50) is not of a current member per the roster provided in exhibit 30. The agency has also not provided a current signed conflict of interest form from an evaluation team member and a public representative for review. Upon notification of an upcoming appeal, the agency policy for conflict of interest, or the appearance of conflict of interest, applied to members of the appeals committee, requires recusal if the Committee member (1) is employed within a state where the parent campus of the institution is located, (2) has voted on the accreditation status of the institution-either during the SACSCOC Board meeting or the meetings of the Committees on Compliance and Reports-at any time leading to the appealable decision, or (3) has served as a member of the site team which visited the institution and resulted in a committee report at any time leading to the appealable decision (exhibit 28). However, the agency did not provide evidence of a recusal, indicate that no recusal has been necessary during this recognition period, or indicate how such recusals were handled as evidence.


Analyst Remarks to Response:

In response to the draft staff analysis, the agency provided additional explanation and documentation. In particular, the agency provided additional explanation on how conflicts of interest and recusals for appeals committee and Board of Trustee members are handled in relation to agency policies on ethical obligations and appeals committee procedures (exhibits 17I, 19J, and 21K). The agency also provided a sample of signed recusal forms for Board of Trustee members (exhibit 20) which includes email correspondence demonstrating how recusals, once identified, are handled by the agency. However, the agency only submitted email exchanges as evidence for the appeals committee recusals and conflicts of interest without signed documents authenticating the members’ emailed attestation (exhibit 18). The site evaluators’ recusals and conflicts of interests are also handled via email without signed authenticated attestations (exhibits 22).



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 evaluates and makes accreditation decisions based upon integrity, compliance with comprehensive standards, core requirements, federal requirements, and agency policies to ensure institutional compliance. The agency determines an institution's compliance with comprehensive standards, core and federal requirements through several layers of review. Institutions are required to submit a compliance certification, which serves as the institution's analysis and assessment of its compliance with standards through documented evidence; a quality enhancement plan that describes the institutions design and focused course of action that addresses topics or issues related to enhancing student learning and evaluation processes. These documents serve as the institutions self-study. These documents are then reviewed by off and on-site review committees, that complete separate reports. The report findings and the institution response are forwarded to the committees on compliance and reports, who makes preliminary recommendations to the executive council. The executive council then makes a final recommendation to the Board who makes the final decision on the institution's accreditation. The agency states that institutions seeking initial or reaffirmation of accreditation must be in compliance with the agency's comprehensive standards, as well as core and federal requirements. Specifically, agency requirements for student achievement include institutions compliance with comprehensive standards 3.3.1 - institutional effectiveness as it relates to outcomes and improvements, 3.5.1 - education competencies and the extent to which students attain them; core requirement 2.5, in which institutions engage in institution-wide research-based planning and evaluation processes; and federal requirement 4.1, which requires institutions to evaluate success with respect to student achievement consistent with its mission (exhibits 14 and 52). The aforementioned compliance requirements and accreditation standards demonstrates the agency's adequate review of various aspects of student achievement. The agency requires all institutions seeking accreditation, including programs offered via distance education, to comply with agency student achievement standards and requirements. The agency allows institutions to establish their own student achievement measures. However, the agency provides supplemental interpretations of standards and guidance to institutions which requires documented success with respect to student achievement including the institutions consideration of enrollment data; retention, graduation, course completion, and job placement rates; state licensing examinations; student portfolios; or other means of demonstrating achievement of goals (exhibit 14). The agency expects institutions to demonstrate successful student achievement, indicate the criteria and threshold of acceptability for success, and provide evidence using data to demonstrate improvement of student achievement. These expectations are examined and analyzed through the off and on-site committees and reported back to the decision making bodies for further review, recommendation and action. However, the agency has not provided sufficient detail of the ways in which the agency evaluates the appropriateness and effectiveness of the student achievement measures established by the institution. The agency provided reaffirmation reports (exhibits 37, 40-41, 91 and 93) and compliance certifications (exhibits 53-54, and 57) for several institutions to demonstrate the off and on-site committee review of the core, comprehensive and federal requirements of the agency, including the review of distance education. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation. The agency also provided additional training materials on institutional effectiveness from the December 2016 annual meeting observed by Department staff (exhibits 18 and 23), the policy on distance and correspondence education (exhibit 101), and the agency's policy on institutional obligations for public disclosure, which requires all institutions to publish statements of goals for student achievement and the success of students in achieving those goals (exhibit 100), as evidence.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of an institution’s student achievement measures compliance with agency requirements for student achievement (exhibits 25-28, 29-32 and 50). The agency then provided additional explanation on how the appropriateness and effectiveness of the student achievement measures established by the institution are evaluated by the agency to demonstrate compliance with the criteria. The agency details the analysis of an institutions compliance with Federal Requirement 4.1 for student achievement, since providing clarifying language to the agency’s resource manual for accreditation. The agency further notes that through the review of narratives from committee reports, which identified student achievement criteria consistent with the mission, the agency was able to document the percentage of reviewed institutions found non-compliant with Federal Requirement 4.1 at each stage of the review. This information is then provided for the last three years on the reaffirmation classes chart provided as evidence (exhibit 29). The agency also reviewed completion data from the National Student Clearinghouse, which was provided in two charts within exhibit 29, citing findings in the data to improve the agency’s practices for collecting data on student achievement.



602.16(a)(1)(ii) Curricula

(a)(1)(ii) Curricula.


The agency states that institutions seeking initial or reaffirmation of accreditation must be in compliance with the agency's comprehensive standards, as well as core and federal requirements. Specifically, agency requirements for compliance with curriculum include the following comprehensive standards: 3.4.10 Responsibility for curriculum; 3.5.1 General education competencies;. 3.5.3 Undergraduate program requirements.; 3.6.1 Post-baccalaureate program rigor; 3.6.2 Graduate Curriculum; 3.6.4 Post-baccalaureate program requirements. These standards are found in exhibits 14 and 52. The agency requires compliance with the following core requirements for curriculum as well: 2.7.2 Program content; 2.7.3 General Education. Associate degree completion requires a minimum of 15 semester hours or the equivalent; and baccalaureate programs require a minimum of 30 semester hours or the equivalent. If an institution uses a unit other than semester credit hours, it provides an explanation for the equivalency and a justification, if it allows for fewer than the required number of semester credit hours or its equivalent unit of general education courses (exhibits 14 and 52). Lastly, the agency requires institutions to be compliant with Federal Requirement 4.2, Continuing education/service programs, which requires curriculum to be directly related to the mission of the institution. The aforementioned comprehensive accreditation standards, core, and federal requirements demonstrates the agency has adequate standards to review institution's curriculum. The agency included the policy on distance and correspondence education, since it is expected that institutions that administer distance education or correspondence education follow the accreditation guidelines as it pertains to curriculum and instruction within the policy (exhibit 101). The agency also provided compliance certifications (exhibits 54 and 56-58) and reaffirmation reports (exhibits 92, 96 and 98), to demonstrate the agency’s review of the aforementioned core, comprehensive and federal requirements, including the review of distance education, as evidence. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s curricula with agency requirements and standards (exhibits 30, 35-44, 51 and 53-55).



602.16(a)(1)(iii) Faculty

(a)(1)(iii) Faculty.


The agency states that institutions seeking initial or reaffirmation of accreditation must be in compliance with the agency's comprehensive standards, as well as core and federal requirements. Specifically, agency requirements for compliance with faculty include the following comprehensive standards: 3.4.10. Responsibility for curriculum, content, quality, and effectiveness of curriculum mainly is a faculty responsibility; 3.4.1. Academic program approval, faculty approves academic credits; 3.5.4 Terminal degrees of faculty, 25 percent of course hours taught are by faculty with appropriate degrees; 3.7.1 Faculty competence, competent faculty members with the highest degree in specific discipline to accomplish the mission; the and goals of the institution; 3.7.2, Faculty evaluation, regular evaluation of faculty effectiveness; 3.7.3, Faculty development, ongoing professional development of faculty; 3.7.4, Academic freedom, is in place for faculty are in place; and 3.7.5 Faculty, the role in governance, policies and academics rest with faculty. These standards are found in exhibits 14 and 52. The agency requires compliance with the following core requirement for faculty as well: 2.8 Faculty, is adequate to support the mission, teaching, research, and/or services while ensuring the quality and integrity programs (exhibits 14 and 52). The aforementioned core requirements and comprehensive accreditation standards demonstrates the agency has adequate standards to review an institution's faculty. Overall, the agency requirements embedded throughout the agency standards for faculty includes institutional requirements of a sufficient number of faculty; faculty approval for educational programs; faculty's primary responsibility over the content, quality, and effectiveness of curriculum; qualified faculty that are provided opportunities for professional development and are evaluated by the institution. The agency included the policy on distance and correspondence education, since it is expected that institutions that administer distance education or correspondence education follow the accreditation guidelines as it pertains to faculty (exhibit 101). The agency also provided compliance certifications (exhibits 60-62) and reaffirmation reports (exhibits 93-95), which includes the review of distance education, to demonstrate adherence to the aforementioned comprehensive standards and core requirements of the agency. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s faculty with agency requirements and standards (exhibits 31, 46-50, 52 and 56-60).



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

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


The agency states that institutions seeking initial or reaffirmation of accreditation must be in compliance with the agency's comprehensive standards, as well as core and federal requirements. Specifically, agency requirements for compliance with facilities, equipment, and supplies include the following comprehensive standards: 3.11.1, Control of physical resources, demonstrates control over all its physical resources; 3.11.2 Institutional environment, a healthy, safe; and secure environment for all; 3.11.3 Physical facilities, are operated and maintains physical facilities, to support mission-related activities (14 and 52). The agency requires compliance with the following core requirement for facilities, equipment, and supplies as well: 2.11.2; physical resources support the mission of the institution (exhibits 14 and 52). The aforementioned core requirements and comprehensive accreditation standards demonstrates the agency has adequate standards to review institution’s facilities, equipment, and supplies .Overall, the agency requirements embedded throughout the agency standards for facilities, equipment, and supplies includes institutional requirements such as adequacy of physical resources, the exercise of appropriate control over its physical resources, and provisions for a healthy, safe, and secure environment. The agency also included the policy on distance and correspondence education, since it is expected that institutions that administer distance education or correspondence education follow the accreditation guidelines as it pertains to facilities and equipment (not faculty as stated in the agency narrative), which is found in exhibit 101. The agency also provided compliance certifications (exhibits 53, 56 and 59) and reaffirmation reports (exhibits 98-99), which includes the review of distance education, to demonstrate adherence to the aforementioned comprehensive standards and core requirements of the agency. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s facilities, equipment, and supplies with agency requirements and standards (exhibits 32, 51 and 61-65).



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

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


The agency states that institutions seeking initial or reaffirmation of accreditation must be in compliance with the agency's comprehensive standards, as well as core and federal requirements. Specifically, agency requirements for compliance with fiscal and administrative capacity include the following comprehensive standards: 3.2.7, Organizational structure, which must be clearly defined and published for policy administrators; 3.2.8, Qualified administrative/academic officers, which are experienced and competent administrative and academic staff; 3.2.10, Administrative staff evaluations, conducts periodic evaluations of administrator's effectiveness; 3.10.1 Financial stability, maintains stable financial health; 3.10.2 Financial aid audits, federal and state regulations are met through financial audits; 3.10.3, Control of finances, exhibits control over all its financial; 3.10.4, Control of sponsored research/external, demonstrates control over; sponsored research and programs. The agency requires compliance with the following core requirement for fiscal and administrative capacity as well: 2.11.1, Financial resources, the mission is supported by stable financial health (exhibits 14 and 52). The above core requirements and comprehensive accreditation standards demonstrates the agency has adequate standards to review institutions fiscal and administrative capacity. Overall, the agency requirements embedded throughout the agency standards for fiscal and administrative capacity demonstrate appropriate expectations for the criteria, and include institutional requirements such as the institution's financial history, financial control, and qualifications and competence of administrators and academic officers. The agency included the policy on distance and correspondence education, since it is expected that institutions that administer distance education or correspondence education follow the accreditation guidelines as it pertains to fiscal and administrative capacity (exhibit 101). The agency also provided compliance certifications (exhibits 53, 56 and 60) and reaffirmation reports (exhibits 97-99), which includes the review of distance education, to demonstrate adherence to the aforementioned comprehensive standards and core requirements of the agency. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation. The Department's "Performance Data By Accreditor" spreadsheet demonstrated failing financial responsibility composite scores for the following institutions accredited by the agency: Everglades University, Emmanuel College, and Kentucky Wesleyan College, prior to the agency's renewal petition submission. This discovery prompted Department staff to request additional information on the financial oversight of these particular institutions (Department uploaded document). The agency addressed the request for additional information on the financial health of these institutions as follows: Everglades University: Everglades University is a SACS accredited institution owned by the corporate body Everglades College, which also owns Keiser University. The agency discovered, during the comprehensive review of Everglades University in 2015, that the corporate body (Everglades College, Inc.) reported the acquisition of the majority of the assets and liabilities of Keiser University in 2011 to the IRS, which was included in financial statements for Everglades University, since Everglades College, Inc. owns both entities, resulting in the Everglades College, Inc. composite financial score being less than the minimum 1.5. However, the agency's reaffirmation committee found that the Everglades University composite financial score, separate from Everglades College, Inc., was an acceptable score of 3.0 and the University was protected from liability of the corporate bodies' debt. Thus, after the completion of the comprehensive review by the agency, Everglades University was reaffirmed with no issues in the area of finances, however, the full cycle of review of Everglades University has not been provided for analysis by the Department. In December 2013, Kentucky Wesleyan College submitted the agency required fifth-year interim report. After the review of the fifth-year interim monitoring report and a requested referral report, the institution was found out of compliance with the Department's financial responsibility score and the agency's aforementioned comprehensive standards and core requirements for financial resources by the Board. The institution was placed on Warning in 2014, which required a monitoring report to the Board in 2015 for review, which resulted in the continued status of Warning. The institution was required to submit a second monitoring report in 2016 with the inclusion of financial documents and audits, in which the Board reviewed and concluded to continue the institutions accreditation for good cause and placed the institution on probation. The Board also required the institution to submit a third monitoring report on the institutions financial resources and authorized a visit to the institution by a Special Committee for an on-site review of the requested report and documents. After review of the institutions third monitoring report and the Special Committee's findings of financial stability at the institution, the Board removed the institution from probation. The findings from the reports are summarized in exhibit 102 along with the Board decision letters and documentation of the adherence to federal and agency timelines for adverse actions. Emmanuel College The agency review of the financial status of Emmanuel College will not be concluded until June 2017. However, the agency's off-site reaffirmation committee preliminary findings from April 2016 found the institution out of compliance with comprehensive standard 3.10.1 and core requirement 2.11.1in April. A response from the institution and an on-site review conducted in November 2016 resulted in the retaining of the non-compliant status of comprehensive standard 3.10.1 and the removal of the non-compliant status of the core requirement by the on-site review committee (exhibit 102).


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s fiscal and administrative capacity with agency requirements and standards (exhibits 33, 51, 54, and 61-67). In addition, the agency responded to the additional information request and the third party comment for Everglades University, Keiser University and Emanuel College. Due to the large size of the documents, the agency provided documents to the Department to Upload in response to this section. Specifically, the agency provided the following: Everglades University The agency provided the following documents for review: quality enhancement plan reaffirmation reports, agency notifications and decision letters, compliance certification, audit findings, and an audit report (exhibits 75-80 and Everglades Analyst uploads) . The evidence provided is consistent with the agency documented history of the institution’s status provided in the original narrative . Keiser University; The agency provided available evidence demonstrating the review of the institution consistent with their established policies and procedures. These documents include reaffirmation reports, a substantive change request, agency notifications and decision letters, compliance certification, audit findings and audit reports (exhibits 81-90 and Keiser Analyst uploads). However, action is pending on the current reaffirmation of accreditation for institution which is scheduled for review December 2017. Emanuel University The agency submitted information demonstrating preliminary findings of the financial health of the institution. The current reaffirmation reports for the institution demonstrate findings of the site evaluators have found standards 2.11.1, 3.2.2.2, and 3.10.1 for financial stability, have not been met. The off and on-site reaffirmation committees concur that until an agreement is in place and the impact on the finial position of the institution is known, financial stability remains in question and cannot be determined at this date, even though the institution has a strategic plan in place and a forbearance of debit. However, Board action is pending on the current reaffirmation of accreditation for the institution, which is scheduled for June 2017 (90-91).



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

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


The agency states that institutions seeking initial or reaffirmation of accreditation must be in compliance with the agency's comprehensive standards, as well as core and federal requirements. Specifically, agency requirements for compliance with student support services include the following comprehensive standards: 3.3.1.3, academic and student support services, which includes such areas as learning resources, tutoring, financial aid, and residence life; 3.9.1, Student rights, which is a clear and appropriate statement of student rights and responsibilities published for the campus; 3.9.2, Student records, the integrity and confidentiality of student records are securely protected with back up data; and 3.9.3, Qualified staff, are appropriate in size and knowledge to accomplish the mission. The agency requires compliance with the following core requirement for student support services as well: 2.10, Student support services, provide services and activities consistent with the intuitional mission, while promoting student learning and development (exhibits 14 and 52). The above core requirements and comprehensive accreditation standards demonstrates the agency has adequate standards to review institution’s student support services. Overall, the agency requirements embedded throughout their standards for student support services includes institutional requirements such as the institution must provide student support programs, services, and activities consistent with its mission while promoting student learning, enhancing the development of its students, protecting student records, and providing a sufficient number of qualified staff. The agency included the policy on distance and correspondence education, since it is expected that institutions that administer distance education or correspondence education follow the accreditation guidelines as it pertains to student support services (exhibits 101). To ensure thorough review of the student support services, the agency in collaboration with institutional evaluators, created a training module for evaluators of student services (exhibit 19). The agency also provided compliance certifications (exhibits 53 and 56) and reaffirmation reports (exhibits 38, 97-99), which includes the review of distance education, to demonstrate adherence to the aforementioned comprehensive standards and core requirements of the agency. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s student services with agency requirements and standards (exhibits 34, 51, 61, and 63-69).



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

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


The agency states that institutions seeking initial or reaffirmation of accreditation must be in compliance with the agency's comprehensive standards, as well as core and federal requirements. Specifically, agency requirements for compliance with recruiting and other practices include comprehensive standard 3.4.3, admissions policies, which requires institutions to publish admissions policies that are consistent with its mission. The agency also requires institutions to be compliant with Federal Requirements 4.3, publication of policies, which requires the institution makes available to students and the public current academic calendars, grading policies, and refund policies; and 4.6, recruitment materials, which states that recruitment materials and presentations accurately represent the institution's practices and policies (exhibits 14 and 52). The Commission guidelines on "Advertising, Student Recruitment, and Representation of Accreditation Status," provides additional information on the federal requirements for recruiting and other practices(exhibit 103), however, the agency does not have and/or require compliance of a core requirement for recruiting and other practices. Overall, the aforementioned federal requirements and comprehensive accreditation standards demonstrates the agency has adequate standards to review institutions recruiting and other practices. In particular, the agency requirements embedded throughout the agency standards for recruiting and other practices requires institutions to ensure current information on academic calendars, and grading and refund policies are publicly available and represent published practices and policies of the institution. The agency included as evidence the policy on distance and correspondence education, since it is expected that institutions that administer distance education or correspondence education follow the accreditation guidelines as it pertains to recruiting and other practices under the student support services section of the policy (exhibit 101). The agency also provided compliance certifications (exhibits 53 and 56) and reaffirmation reports (exhibits 94, 97, 99), which includes the review of distance education, to demonstrate adherence to the aforementioned comprehensive standards in conjunction with the core and federal requirements of the agency. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s recruiting practices with agency requirements and standards (exhibits 34, 35, 51, 58, 61-62 and 65-68).



602.16(a)(1)(viii) Recruiting & Other Practices

(a)(1)(viii) Measures of program length and the objectives of the degrees or credentials offered.


The agency states that institutions seeking initial or reaffirmation of accreditation must be in compliance with the agency's comprehensive standards, as well as core and federal requirements. Specifically, agency requirements for compliance with program length include the following comprehensive standards: 3.4.5 -Academic policies- institutions publish and distribute academic policies that adhere to principles of good educational practice to constituents; 3.5.3 - Undergraduate program requirements - institutions publish these requirements with general education components and commonly accepted standards and practices; 3.6.4 -Post-baccalaureate program requirements- institutions define and publishes requirements for its graduate and post-graduate professional programs with commonly accepted standards and practices The agency requires compliance with the following core requirement for program length as well: 2.7.1 -Program length - associate level at least 60 semester credit hours or the equivalent, baccalaureate level at least 120 semester credit hours or the equivalent, and post-baccalaureate, graduate, or professional level at least 30 semester credit hours or the equivalent; 2.7.2 - Program content -programs directly connected to the instructional mission and to fields of study appropriate to higher education; 2.7.4 - Course work for degrees -institutions offer instruction for all coursework required and responsible for controlling the quality of that program. The agency also requires institutions to be compliant with Federal Requirements 4.4-Program length- programs are of sufficient length for mastery of content; 4.9- Definition of credit hours- policies and procedures for determining the credit hours are in place (exhibits 14 and 52). Overall, the agency requirements embedded throughout the agency standards for program length includes institutional requirements for appropriateness of the program length for each educational program, offerings for one or more degree, and a breakdown of credit hours by degree level. Institution justifications are required for equivalency, which are the units of measure for the degree program other than semester credit hours; and for all degrees that include fewer than the required number of semester credit hours or its equivalent unit. The agency has also provided substantial written guidance to its evaluators regarding how to apply its requirements for program length to institutions that offer distance or correspondence education. The aforementioned comprehensive accreditation standards, core and federal requirements demonstrates the agency has adequate standards to review various aspects of the institutions program length. The agency also included its policy document that defines credit hours for evaluators and those seeking initial or continued accreditation, which outlines the federal definitions of credit hours, and guidance regarding how requirements for program length are applied to institutions that offer distance or correspondence education (exhibit 104). The policy on distance and correspondence education was then included, since it is expected that institutions that administer distance education or correspondence education follow the accreditation guidelines as it pertains to program length under the curriculum and instruction section of the policy (not student services as stated in the agency narrative)(exhibit 101). The agency also provided compliance certifications (exhibits 57 and 58) and reaffirmation reports (exhibits 94, 97 and 99), which includes the review of distance education, to demonstrate adherence to the aforementioned comprehensive standards in conjunction with the core and federal requirements of the agency. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s program length with agency requirements and standards (exhibits 34, 36, 52, 55, 58, 64-67, and 69).



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

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


The agency's principles for accreditation, updated resource manual for the principles of accreditation, and the policy statement for complaint procedures against SACSCOC or Its accredited institutions, clearly outline the institutional requirements for addressing, resolving and tracking student complaints. The accreditation manuals specifically emphasize the agency's federal requirement 4.5, which requires an institution to have adequate procedures for addressing written student complaints and is responsible for demonstrating that it follows those procedures when resolving student complaints. Institutions are also required to comply with the policies of the commission on colleges, which is addressed in comprehensive standard 3.13.1, reiterating the federal requirement for student complaints (exhibits 14, 52 and 105). The agency also requires that each institution has reasonable, fairly administered, and well-publicized student complaint policies and procedures in place. The agency further requires, per federal regulations, that the institution maintains a record of complaints received by the institution. The agency requires site evaluation Committees to review the institution's student complaints and their policies noting patterns found amongst the complaints. If a pattern is found amongst the complaints related to agency standards, the agency reviews the complaints for documentation supporting the allegations; conducts an on-site investigation of the complaints; and the Committee writes a recommendation (a citation of noncompliance), based upon their investigation supporting non-compliance for a standard/requirement of the Principles. However, the agency examples did not demonstrate evidence of the agency’s review of an institution’s handling and decisions on a complaint or evidence of the agencies evaluation of the record of complaints at an institution. The agency provided compliance certifications (exhibits 60-61) and reaffirmation reports (exhibits 93 and 96), which includes the review of distance education, to demonstrate adherence to the aforementioned comprehensive standards and federal requirements of the agency.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s student complaints processes with agency requirements and standards (exhibits 37, 50, 54, 56 and 70-71).



602.16(a)(1)(x) Title IV Responsibilities

(a)(1)(x) Record of compliance with the institution's program responsibilities under Title IV of the Act, based on the most recent student loan default rate data provided by the Secretary, the results of financial or compliance audits, program reviews, and any other information that the Secretary may provide to the agency; and


The agency requires institutions to meet comprehensive standard 3.10.2 and federal requirement 4.7 to demonstrate compliance with Title IV responsibilities (Exhibits 14 and 52). The agency site-team evaluators review institutions adherence to audit requirements of financial aid programs per state and federal regulations, and ensure program responsibilities under the most recent Higher Education Act, as amended, are met for Title IV. The agency works collaboratively with the Department's Federal Student Aid office to ensure federal funds are utilized appropriately at the institution. Upon notification from the Department of problems with Federal Student Aid by a member institution (unsolicited information, exhibit 73), the agency requests recent audits and other financial documentation from the institution for review. Once the agency reviews this documentation, the findings are sent to the Board for action. Special Committees may be enacted for additional monitoring and review based upon the severity of the noncompliance with agency standards and federal requirements. The agency provided a compliance certification (exhibits 56) and reaffirmation reports (exhibits 39 and 91), which includes the review of distance education, to demonstrate adherence to the aforementioned comprehensive standards and federal requirements of the agency. However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s Title IV responsibilities with agency requirements and standards (exhibits 38, 25, 26, 51, and 57).



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 requires an institutional mission to meet the comprehensive, core and federal requirements of the agency. The agency evaluates the mission of the institution to ensure its adherence to comprehensive standard 3.1.1, which requires the institutional mission to be comprehensive, periodically reviewed, updated, communicated, and approved by the governing board; core requirement 2.4, which expects the institution's mission statement to be specific to the institution, appropriate for higher education, and address teaching, learning, research and public service; and federal requirement 4.2, which requires the institution's curriculum to be directly related, to the mission and the awarded outcomes. Through interval monitoring and interim reporting, the agency stays abreast of the institutional status for maintaining these requirements (exhibits 14 and 52). The agency requires all institutions seeking accreditation, including programs offered via distance education or through a consortium, to comply with agency standards and requirements. The agency also evaluates the institutions adherence to stated objectives which is demonstrated through the agency's assessment of standard 3.3.1 (institutional effectiveness) and core requirement 2.5 (planning and evaluation). Evaluation of degree and certificate requirements are monitored by the agency through the institutions core requirements 2.7.1, (program length), 2.7.2 program content, and 2.7.4 (course work for degrees). Lastly, evaluation of comprehensives standards for academic policies, practices for awarding credit, responsibility for curriculum, and general education competencies are reviewed by the agency to ensure institutional compliance through compliance certificates submitted by the institution and the review processes of the agency. The agency submitted as evidence the policy for the quality and integrity of undergraduate degrees, which is a national priority to sharply increase the percentage of Americans holding undergraduate degrees, to assist institution with educational pathways to facilitate accomplishment of the goal of the policy (exhibit 55). The agency provided evidence of institutional adherence and agency review of the criteria in exhibits 41, 53 and 54). However, the agency examples did not demonstrate the full cycle of review, including documentation demonstrating the evaluation of the institution and evidence of the corresponding Board of Trustee’s decision on the institution’s accreditation.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided preliminary and final reaffirmation reports along with the corresponding decision letters to demonstrate the agency’s full cycle of review and evaluation of compliance for an institution’s mission and objectives with agency requirements and standards (exhibits 39, 31, 32, 53 and 61).



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 conducts comprehensive reviews of an institution every 10 years. However, the agency conducts many forms of continuous monitoring of its accredited institutions to demonstrate institution and agency compliance to the criteria. The agency requires institutions to submit the following for continuous monitoring between comprehensive reviews: Fifth year interim reports, which include focused submission of the Compliance Certification of 17 standards directly related to the Secretary’s Criteria (exhibits 65, A-C); and two Institutional profiles, which provides enrollment and financial data using critical indicators to detect negative trends in an institution's finances that warrant the agency to collect additional financial information. The agency has provided an overview of the fifth year interim report process, sections of the fifth year interim report, notification letters to institutions, institutional profile data and templates along with the critical finance indicators used to screen the data (exhibits 65-69). However, the agency has not provided completed fifth year interim reports or a full cycle of review of institutions to demonstrate compliance with the Department’s focused review for this criterion. The agency also conducts non-cyclical monitoring for an institution to assist the agency in identifying problems with continued compliance with agency standards Examples of this monitoring includes its review of thousands of substantive change request; special report monitoring stemming from submission of unsolicited information or complaints, which requires a review and investigation of noncompliance with the of accreditation standards and site visits; general monitoring from previous reviews; and financial information provided by the Department. The agency provided notification letters to institutions requesting additional information as follow up to unsolicited information (exhibit 73) and the Department’s financial information, received by the agency, requiring follow-up by the institution as evidence (exhibits 71-72).


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. The agency did not provide the corresponding reports for the previously submitted institutions; however, the agency did provide fifth year monitoring reports and corresponding decision letters for two institutions that emphasize the off and on-site evaluator’s concerns with the select standards, which were analyzed by Department staff. In particular, the agency provided fifth year reports for two institutions which included a quality enhancement plan; and standards referred for additional reporting and a follow up monitoring report. Board decision letters indicating concurrence with the fifth year review committee’s findings (exhibits 41, 43-45 and 99) are also provided as evidence. The decision letters include instructions for submitting the subsequent monitoring report to address the questions raised during the review and notification to institutions of possible sanctions, failing to comply to the agency’s requests.



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 policy on Sanctions, Denial of Reaffirmation, and Removal from Membership demonstrates the immediate enforcement of an adverse action to be taken against an institution out of compliance with agency standards. The agency further defines the two sanctions an institution may be placed on if noncompliant with standards, which are warning and probation. Institutions are to take appropriate action to come into compliance with agency standards within two years. If an institution has not remedied deficiencies at the conclusion of its two-year maximum monitoring period, the Board must (1) remove the institution from membership or (2) continue accreditation for "good cause". If accreditation is extended for "good cause," which is one year, the institution must also be placed on or continued on Probation per agency policy (exhibit 74). The agency provided sample notification letters for continuous monitoring, probation for good cause, an adverse action and sample disclosure statements (exhibits75 and 76). However, the agency has not provided a full cycle of review of institutions to demonstrate compliance with the Department's focused review for this criterion. Documentation to demonstrate the full cycle of review in this case would be the Board of Trustee decision letter initially finding the institution out of compliance either taking an immediate adverse action or allowing the institution a specific timeframe to demonstrate compliance; interim actions/ documentation; and the final Board of Trustee action finding the institution compliant or awarding the institution an extension for good cause. Additional Information requested by the Accreditation Group: In January 2014, the Department requested information from the agency regarding actions with the University of North Carolina. The agency provided the Department with a timeline of actions pertaining to actions taken with respect to the National Collegiate Athletic Association's (NCAA) Public Infractions report on the University. In September 2016, Department staff received an article discussing the highly publicized NCAA report on bogus classes in the University of North Carolina African American studies department. Therefore, the Accreditation Group requested additional information requiring the agency to address this issue in its petition for renewal of recognition, including documentary evidence demonstrating its review of the University's compliance with its standards, subsequent adverse action if such action was warranted, and the current status of the University. To comply with this request, the agency provided a case review of the University with an updated timeline of actions from 2012 to 2016 in exhibit 78. The agency review of bogus classes within the University's African American studies department began in 2012 per the receipt of unsolicited information (policy found in exhibit 73). The institution was requested to address the concerns and after the review of the University's response, an additional request was made for the University to address specific accreditation principles of the agency. In 2013 a Special Committee visited the University discovering the cause of the issue and after the review of the committee the Board completed its monitoring in early 2014. In the Fall of 2014, the new chancellor of the University received its independent investigation report on the same issue which revealed additional faculty and staff were involved in the academic irregularities of the department in question, resulting in the agency re-launching its investigation into the University's compliance with 18 standards. After review of the University's response, the institution was placed on probation in 2015. Upon further review by additional Special Committee visits and monitoring reports the Board removed the University from probation in 2016 (exhibit 78). In August 2016, Department staff also received information from an article regarding the Governor of Kentucky's (Matt Blevin's) involvement with the Board of Trustees for the University of Louisville. The agency is quoted in the article, stating "the University of Louisville appears to be out of compliance with several significant standards, because of Governor Matt Blevin's June overhaul of the Board of Trustees". Therefore, the Accreditation Group requested additional information requiring the agency to include in its petition for renewal of recognition documentary evidence demonstrating its review of the University's compliance with its standards, subsequent adverse action if such action was warranted, and the current status of the University. In June of 2016, Governor Bevin, announced the reorganization of the University of Louisville Board of Trustees with the appointment of new interim members, that resulted in the resignation of the University President. The Kentucky Attorney General filed an injunction against the Governor's actions, which was granted, allowing the reinstatement of the previous Board members. The agency was then prompted to request that the University provide an explanation and documentation of compliance with core requirement 2.2 (Governing Board), comprehensive standards 3.2.1(CEO selection and evaluation), which were satisfied prior to Board review with implementation of the court injunction, 3.2.4 (External Influence), 3.2.5 (Board Dismissal), 3.12.1 (Substantive change), and other information related to the University's reorganization. In August 2016, the University responded to the agency request and after further review, the agency Board of Trustees placed the University on probation at its December 2016 annual meeting in which Department staff observed the proceedings leading up to this decision.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. The agency restated existing policy for adverse action, which is utilized when an institution does not comply with the agency policies on sanctions, denial of reaffirmation, and removal from memberships (exhibit 46L). The agency then provides six cases demonstrating the use of these policies. The documents demonstrate full cycles of review for denied reaffirmation, reaffirmation with a monitoring report, probation, warning, extension for good cause and the review of a special committee. Specifically, the documents provided demonstrate dated Board communication with the institution including initial contact with the institution listing non-compliant areas; requests for monitoring reports; notification of a special committee visit for additional on-site monitoring, results of the monitoring efforts, designation of a sanction, extension for good cause; and notification of the addition or removal of an adverse action placed on the institution by the agency (exhibits 47-52).



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 policy on Sanctions, Denial of Reaffirmation, and Removal from Membership demonstrates that the agency monitors compliance of agency standards, policies and procedures of an institution over a two year period. An institution with deficiencies at the conclusion of its two-year maximum monitoring period is subject to the following Board actions: (1) removing the institution from membership, or (2) continuing its accreditation for good cause, which also requires the institution to receive the sanction of probation. The agency grants good cause extensions to an institution if it has demonstrated recent and significant accomplishments in addressing non-compliance; documented that it has the potential to remedy all deficiencies within the extended period with evidence as defined by the Committee on Compliance and Reports; and provides assurance to the Board that it is not aware of any other reasons, other than those identified, why the institution could not be continued for good cause (exhibit 74). The agency policy explains that good cause extensions may be one or a maximum of two years. However, if an institution was on Probation both years of its two-year monitoring period following initial action on deficiencies, the institution is not eligible for good cause consideration because an institution cannot be on probation for more than two consecutive years and good cause extensions imposes automatic probation, which would exceed the two year time limit for the probation status. The agency has provided a summary of the Board approved good cause extensions of accreditation over the last five years to demonstrate the infrequent and judicious granting of these request. Exhibit 79 displays that 34 good cause extension requests were granted from 2012-2016 out of 1,984 cases. Of the 34 cases, the Board took action to remove the accreditation of 7 due to failure to comply the agency's standards. However, the agency has not provided a full cycle of review of institutions to demonstrate compliance with the Department's focused review for this criterion. Documentation to demonstrate the full cycle of review in this case would be the Board of Trustee decision letter initially finding the institution out of compliance either taking an immediate adverse action or allowing the institution a specific timeframe to demonstrate compliance; interim actions/ documentation; and the final Board of Trustee action finding the institution compliant or awarding the institution an extension for good cause.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency resubmitted the agency policy on good cause extensions and six cases demonstrating full cycles of review for denied reaffirmation, reaffirmation with a monitoring report, probation, warning, extension for good cause and the review of a special committee (exhibits 47-53). Specifically, the documents provided demonstrate dated Board action and communication with the institution including initial contact with the institution listing non-compliant areas; requests for monitoring reports; notification of a special committee visit for additional on-site monitoring, results of the monitoring efforts, designation of a sanction, extension for good cause; and notification of the addition or removal of an adverse action placed on the institution by the agency. The agency evidence exhibits the use and execution of a good cause extension according to the criteria.



602.22(a)(1) Approval of Substantive Changes

(a) If the agency accredits institutions, it must maintain adequate substantive change policies that ensure that any substantive change to the educational mission, program, or programs of an institution after the agency has accredited or preaccredited the institution does not adversely affect the capacity of the institution to continue to meet the agency's standards. The agency meets this requirement if--

(1) The agency requires the institution to obtain the agency's approval of the substantive change before the agency includes the change in the scope of accreditation or preaccreditation it previously granted to the institution; and


The agency provided the policies, procedures and good practices for institutions seeking approvals of substantive changes demonstrating adherence to the Secretary's criteria. Specifically, the agency provided the substantive change policy and definition for agency accredited institutions, which requires institutions to notify the agency of changes in a timely manner prior to the initiation of the changes, since approval is required. The agency also provides a policy statement on institutional mergers, consolidations, change of ownership, acquisitions, along with change of governance, control, form, or legal status of an institution in addition to complying with the agency requirements for reporting of the agency defined types of substantive requests from the institution. Lastly, policies and procedures related to good practices for institutions seeking to close a program, site, branch, or institution, which includes the options to consider for such requests (exhibits 80, 81, and 83) has been included by the agency to advise institution on best practices and ensure the substantive change does not adversely affect the capacity of the institution to continue to meet the agency's standards. The agency has provided a portion of an application for a member institution seeking accreditation at a different degree level, redacted minutes of substantive change discussions by the agency's Committee on Compliance Reports; and letters of notification approving and denying substantive change request (exhibits 83-85). However, the agency has not provided evidence of a full cycle of review for institutions substantive change requests for Department staff to analyze. Evidence of a full cycle of review would include the initial substantive change request identifying the type of change, agency review, recommendations and decision letters from the decision making body for substantive change.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation in an attempt to address Department staff concerns. In particular, the agency provided two examples of substantive changes (exhibit 54 and Analyst upload). The exhibit 54 demonstrates a program level substantive change. The full cycle of review includes the proposal presented to the agency for the change; the agency response with follow up instructions for additional information and review; the institutions return of the requested documents; and Board approval from the agency. However, the Analyst upload only includes the substantive change proposal from the four agency accredited institutions that will merge/consolidate; no additional information, such as, agency acceptance, site evaluation report, and/or Board decision letters are included for analysis.



602.22(a)(2)(i-vii) Types of Substantive Change

(2)The agency's definition of substantive change includes at least the following types of change:

(i) Any change in the established mission or objectives of the institution.

(ii) Any change in the legal status, form of control, or ownership of the institution.

(iii) The addition of courses or programs that represent a significant departure from the existing offerings of educational programs, or method of delivery, from those that were offered when the agency last evaluated the institution.

(iv) The addition of programs of study at a degree or credential level different from that which is included in the institution's current accreditation or preaccreditation.

(v) A change from clock hours to credit hours.

(vi) A substantial increase in the number of clock or credit hours awarded for successful completion of a program.

(vii) If the agency's accreditation of an institution enables the institution to seek eligibility to participate in title IV, HEA programs, the entering into a contract under which an institution or organization not certified to participate in the title IV, HEA programs offers more than 25 percent of one or more of the accredited institution's educational programs.


The agency has an established policy on substantive change for agency accredited institutions, which states that substantive change is a significant modification or expansion of the nature and scope of an accredited institution (81). The federal requirements listed in the Secretary's criteria are included as part of the agency's definition of substantive change except for iv, which states that the addition of programs of study at a degree level or credential level different from which is included in the institution's current accreditation or preaccrediation is a substantive change. Agency examples of substantive change decisions in 602.20 (exhibit 85). However, the agency has not provided evidence of a full cycle of review for institutions substantive change requests for Department staff to analyze. Evidence of a full cycle of review would include the initial substantive change request identifying the type of change, agency review, recommendations and decision letters from the decision making body for substantive change.


Analyst Remarks to Response:

In response to the draft analysis, the agency provided additional explanation and documentation to demonstrate compliance with the criteria. In particular, the agency provided the substantive change policy with the inclusion of federal requirement 602.22 (a)(iv); the substantive change approvals from the December 2016 annual meeting; and a letter from the President of the agency citing the inclusion of a substantive change at the degree level to an institution. The agency also includes a substantive change full cycle of review at the degree level to further demonstrate compliance. The full cycle of review includes the proposal presented to the agency for the change; the agency response with follow up instructions for additional information and review; the institution’s return of the requested documents; the agency site visit report documents; and Board approval from the agency.



Part III: Third Party Comments


Staff Analysis of 3rd Party Written Comments

The Department has received three third-party comments pertaining to the renewal of recognition for the agency. Two of the comments raise concerns with the Secretary’s criteria (602.18(b)) and agency requirements for the consistent and adequate enforcement of standards, with respect to Everglades College and Keiser University. The Department’s Performance Data by Accreditor spreadsheet demonstrated failing financial responsibility composite scores for Everglades University prior to the agency’s renewal petition submission, which prompted the Accreditation Group to request additional information on the financial health and oversight of Everglades University. The agency provided additional information that revealed Everglades College, which is not accredited by the agency, serves as the corporate entity that owns Everglades and Keiser University, who are accredited by the agency. However, Department staff has requested additional evidence from the agency concerning adherence to the Secretary’s criteria and the agency’s policies, procedures, and standard requirements for further compliance review. In addition to the above concerns, one of the aforementioned commenters requests the recusal of the Chair of NACIQI, due to conflicts of interests associated with their professional association with Everglades College and Keiser University. However, this request is outside the confines of the scope of recognition review. This information will be forwarded to the Executive Director for the NACIQI for action. The third commenter raises concerns regarding the agency’s standards on student outcomes, institution performance, and Board member representation under federal regulations. The concerns, are related to the following criteria: student achievement 602.16(a)(1)(i), Separate and Independent status 602.14(b), 602.15(a)(5) Public Representatives, and 602.15(a)(6) Conflict of Interest. The agency’s accreditation standards, has been reviewed by the Department and additional evidence has been requested from the agency. It should be noted that the Higher Education Act, as amended, Section 496 states “Nothing in this Act shall be construed to permit the Secretary to establish criteria for accrediting agencies or associations that are not required by this section. Nothing in this Act shall be construed to prohibit or limit any accrediting agency or association from adopting additional standards not provided for in this section. Nothing in this section shall be construed to permit the Secretary to establish any criteria that specifies, defines, or prescribes the standards that accrediting agencies or associations shall use to assess any institution’s success with respect to student achievement.” However, the Department invites the agency to respond to the third party commenters in the corresponding sections of their petition response.