American Osteopathic Association 05/22/2018 04/10/2018 Final Review Compliance Report

U.S. Department of Education

Staff Report

to the

Senior Department Offical

on

Recognition Compliance Issues


Recommendation Page



  1. American Osteopathic Association
  2. Compliance Report
  3. The accreditation and preaccreditation ("Provisional Accreditation") throughout the United States of freestanding, public and private non-profit institutions of osteopathic medicine and programs leading to the degree of Doctor of Osteopathy or Doctor of Osteopathic Medicine.
  4. Same as above.
  5. May 22, 2018
  6. Renew the agency's recognition for three years
  7. None

Executive Summary



Part I: General Information About The Agency

The Commission on Osteopathic College Accreditation (COCA) is a standing committee of the American Osteopathic Association (AOA). The COCA currently accredits 23 osteopathic colleges of medicine and provisionally accredits another six. Because these osteopathic medical education programs may be offered in either freestanding institutions offering only these programs or in larger institutions offering other educational programs, the agency is considered both an institutional and programmatic accreditor. Of the 29 colleges of osteopathic medicine accredited or provisionally accredited by AOA COCA, three are located in freestanding institutions. For these institutions, AOA COCA accreditation is a required element in enabling them to establish eligibility to participate in Title IV, HEA programs. The Department received no third party comments in reference to AOA COCA's compliance report.

Recognition History

The AOA COCA, as previously configured, was first recognized by the U.S. Commissioner of Education in 1952 and has received periodic renewal of recognition since then. The agency was last reviewed for continued recognition at the August 2016 NACIQI Meeting, when the Senior Department Official issued a decision in October 2016 that required the agency to come into compliance with many areas of the Secretary's criteria within twelve months, and submit a compliance report 30 days thereafter demonstrating the agency's compliance with the criteria as cited in the decision letter. The agency's compliance report is the subject of this analysis.


Part II: Summary Of Findings

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.


Previous Issue: After review of the evidence and follow-up communication with the agency, the agency definition for pre-accreditation status is inconsistent with the Department definition found within 602.3. Also, the agency definition of provisional accreditation coincides with the Department definition of pre-accreditation found in 602.3. However, COM accreditation standards and procedures do not reflect a clear distinction between the two terms and in some instances pre-accreditation and provisional accreditation are utilized interchangeably, thus deeming the agency non-compliant with this criterion. Discussion: The agency is now compliant with this criterion. It has revised its accreditation process terminology, including elimination of the term “provisional accreditation”. The agency’s accreditation process now includes three distinct stages that occur prior to an institution gaining accreditation status. These stages include applicant status; candidate status; and pre-accreditation status. The process and stages are clearly defined in the agency’s Accreditation of Colleges of Osteopathic Medicine: COM New & Developing Accreditation Standards, effective July 1, 2017 (see Exhibit #6) and its most recent Accreditation of Colleges of Osteopathic Medicine: COCA Policies and Procedures, effective August 28, 2017 (see Exhibit #8); page 29 of this manual states that “[i]f the COM has not been able to proceed to Accreditation status within five years of the granting of Pre-Accreditation Status, the Pre-Accreditation Status will be withdrawn,” which is aligned with regulations. The agency’s use of “pre-accreditation” now reflects the Department’s intent of the phrase without referencing “provisional accreditation”. Also, under its revised policy, the agency has had an opportunity to award the proposed Idaho College of Osteopathic Medicine “pre-accreditation status” (see Exhibit #159). Further, in accordance with 602.3, the agency accredits osteopathic medical schools and their programs at 34 osteopathic medical schools and their collective 49 sites are located in 32 states, including Alabama, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Illinois, Indiana, Iowa, Kentucky, Maine, Michigan, Mississippi, Missouri, Nevada, New Jersey, New Mexico, New York, North Carolina, Oklahoma, Ohio, Oregon, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virginia, Washington, and West Virginia (see Exhibit #1).




602.13 Acceptance of the agency by others.

The agency must demonstrate that its standards, policies, procedures, and decisions to grant or deny accreditation are widely accepted in the United States by--

(a) Educators and educational institutions; and

(b) Licensing bodies, practitioners, and employers in the professional or vocational fields for which the educational institutions or programs within the agency's jurisdiction prepare their students.


Previous Issue: The agency narrative explains the different individuals and groups in which wide acceptance of agency standards, policies, procedures, and decisions for accreditation are accepted by the aforementioned stakeholders. Examples of these groups include employers of graduates, stakeholders, Directors of Medical Education, etc. However, the agency has not provided any evidence supporting the narrative claims for review by the Department as no documentation was uploaded by the agency. Discussion: The agency is now compliant with this criterion. It has provided ample evidence supporting its initial narrative claim of wide acceptance of its “standards, policies, procedures, and decisions to grant or deny accreditation by educators and educational institutions, practitioners; and employers in the professional or vocational fields for which the educational institutions or programs within [its] jurisdiction prepare their students”. The evidence includes numerous letters of support (nearly 50) from schools of osteopathic medicine, medical centers, and hospitals, etc. (see Exhibit #s 11-38; 151-158; 161-164). To further describe its broad acceptance, the agency also provided website links to sample state medical practice acts, supporting how “state medical licensing laws require graduation from a COCA accredited osteopathic medical school as one of the criteria for licensure” (see Exhibit #10). In addition, the agency provided a list of requirements for participating in the National Resident Matching Program (NRMP), which recognizes students who attend the agency’s accredited schools and allows them to apply for residency matching services for over 30,000 positions (see Exhibit #9).




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;


Previous Issue: In response to the draft analysis, the agency narrative attests that site visit teams include individuals representing all stakeholder groups of the agency. However, the academic personnel required by the criteria is not clearly defined in the evaluator manual as well as the site visit compositions included as evidence. Also, it is unclear in the narrative and the evaluator manual if a single individual fulfills one defined category/role at a time on the site review teams. Discussion: Although the agency has made commendable attempts to demonstrate compliance with this criterion, it needs to provide evidence that reflects its most recent policy revisions. The agency has clearly defined the required academic personnel criteria in its Commission on Osteopathic College Accreditation Evaluator Manual (see Exhibit #45), effective September of 2017, although evidence of its official approval has not been submitted (was predicted for December 2017). The manual (page 10) explains that site visit team members must consist of a practitioner, educator, academic, and administrator as required by regulation. Further, the agency’s narrative explains that site visit teams typically have five members: one who focuses on administration and finance; another who investigates student services; another who reviews pre-clinical education; and two other staff who focus on clinical education. In some cases, trainees and observers participate in the site visits. The manual also explains that pre-accreditation and comprehensive site visit teams are usually comprised of one team chair; one administrator; one or two academics; one educator; one practitioner; an evaluator trainee when applicable; and one or two COCA staff member/s. The agency also provided actual examples of site visit agendas and reports from three institutions to illustrate that their team members have clearly assigned and non-overlapping roles that comply with the Department’s requirements. These examples are from the Alabama College of Osteopathic Medicine (see Exhibit #s 39 & 40), the Arkansas College of Osteopathic Medicine (see Exhibit #s 41 & 42); and Campbell University’s Jerry M. Wallace School of Osteopathic Medicine (see Exhibit #s 43 & 44). Although these examples from three institutions clarify the discreet roles of each of the site visit team members, the site visit report examples that were used as evidence are from the period in time when the agency used the term “provisional accreditation”. Using examples that comply with its revised policy and does not refer to “provisional accreditation” would be appropriate. The agency should work diligently to provide documentation as noted by Department staff. The agency will have 30 days to respond to the draft staff analysis; at which time, it should provide site visit agendas and reports aligned with its revised policy regarding the deletion of “provisional accreditation”.




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.


Previous Issues: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to student achievement. The agency is compliant with this criterion.




602.16(a)(1)(ii) Curricula

(a)(1)(ii) Curricula.


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to curricula. The agency is compliant with this criterion.


Analyst Remarks to Response:

Issue-- The agency should work diligently to provide documentation as noted by Department staff. The agency will have 30 days to respond to the draft staff analysis; at which time, it should provide site visit agendas and reports aligned with its revised policy regarding the deletion of “provisional accreditation”. [§602.15(a)(3)] Discussion: As a result of its required policy change, the COCA has now provided the requested site visit agendas and their associated reports from three institutions that appropriately integrate the use of the term “pre-accreditation” rather than referring to the misuse of “provisional accreditation”. These site review documents—from (1) Liberty University College of Osteopathic Medicine, conducted February 7-9, 2018 (See Exhibit #1); (2) the University of Incarnate Word School of Osteopathic Medicine, conducted February 14-16, 2018 (See Exhibit #2); and (3) the Idaho College of Osteopathic Medicine, conducted March 8-9, 2018 (See Exhibit #3)—reflect the revised policy. The agency is now compliant with this criterion.



602.16(a)(1)(iii) Faculty

(a)(1)(iii) Faculty.


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to faculty. The agency is compliant with this criterion.




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

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


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to facilities/equipment/supplies. The agency is compliant with this criterion.




602.16(a)(1)(ix) Student Complaints

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


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to student complaints. The agency is compliant with this criterion.




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

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


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to fiscal administration capacity. The agency is compliant with this criterion.




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

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


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to student support services. The agency is compliant with this criterion.




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

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


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to recruiting and other practices. The agency is compliant with this criterion.




602.16(a)(1)(viii) Program Length

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


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to program length. The agency is compliant with this criterion.




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


Previous Issue: The agency (1) does not detail how the self-study, which is notably lengthy, is reviewed and referenced throughout the accreditation review process. Also, the agency’s narrative (2) does not mention the presentation and review of the self-study by the commissioners/decision making body, only the review of the site visit report. Moreover, (3) an explanation of how documents related to student achievement and outcomes are being reviewed, particularly the self-study, is needed to verify compliance with the criteria. Finally, in accordance with the June 3, 2013 Department memo, the (4) agency must provide additional information and documentation to illustrate its accreditation review and decisions of several institutions in order for Department staff to determine whether the agency consistently applies its accreditation standards and policies. Discussion: The agency has now explained how its accredited institutions’ self-studies are reviewed and referenced throughout the accreditation process, and it has summarized how the commissioners/decision makers review the self-studies without a simple reliance on the site visit report that it provided in an earlier submission. Specifically, the agency’s narrative explains that its institutions (COMs) submit their self-studies, which address the domains, standards, and elements of the accreditation standards for compliance, including verifiable information for any claims made (see Exhibits #s 49A-E & 68). The agency’s site visit team members review the self-studies along with supporting documentation before and during the actual site visits, and the team generates site visit reports after the on-site reviews (see Exhibits #s 39, 40, 76, & 84). After the reviews, COMs have an opportunity to review the reports for accuracy. Then, the agency reviews the reports and determines whether the COMs are compliant with each standard. The agency can reach out to the COMs for clarification or additional information. The agency commissioners make the final accreditation decision as to whether the standards have been met by reviewing the self-studies, site visit reports, and any information gathered as follow-ups (see Exhibit #s 58, 66, & 87). Areas of non-compliance are monitored through progress reports that the agency commissioners use to further review and evaluate the COMs progress toward compliance. Progress reports (see Exhibit # 64) are addressed at the following agency meetings, and institutions receive notification letters (see Exhibit #s 67 & 88). The agency also produces state notification letters (see Exhibit #s 61 & 89) and press releases (see Exhibit #s 62 & 90). To illustrate that it consistently applies its accreditation standards and policies, the agency provided information and documentation from two institutions’ accreditation cycles: Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40 & 49-67] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90]. Because the ACOM (programmatically and institutionally accredited by the agency) is going through its initial accreditation request, there is no annual reporting or mid-cycle review that can be submitted at this time. However, documents from the Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM), which is programmatically accredited by the agency, include an annual report review, a mid-cycle review, a self-study, a site visit report, and an agency decision for a comprehensive accreditation visit. In addition to ACOM and MWU-CCOM, the agency submitted full accreditation cycle reviews for Lake Erie College of Osteopathic Medicine (LECOM) under Criteria Sections 602.17(a), 602.19(b), and 602.26(b) (see Exhibit #s 105-118) and for Nova Southeastern University College of Osteopathic Medicine (NSU) under Criteria Section 602.17(a) (see Exhibit #119-133). These institutions’ collective documentation for their self-studies, annual reports, mid-cycle reviews, and progress reports along with the agency's site visit reports address, directly or indirectly, the required information related to Title IV responsibility. The agency is compliant with this criterion.




602.16(a)(2) Preaccreditation Standards

(a)(2) The agency's preaccreditation standards, if offered, are appropriately related to the agency's accreditation standards and do not permit the institution or program to hold preaccreditation status for more than five years.


Previous Issue: The agency definitions for pre-accreditation and provisional accreditation are inconsistent with the Department's definition for pre-accreditation in 602.3. The agency standards, policies and procedures must identify a clear distinction between the two terms consistent with the Department's criteria and the approved scope of recognition for the agency. Discussion: The agency is now compliant with this criterion. It has revised its accreditation process terminology, including elimination of the term “provisional accreditation”. The agency’s accreditation process now includes three distinct stages that occur prior to an institution gaining accreditation status. These stages include applicant status; candidate status; and pre-accreditation status. The process and stages are clearly defined in the agency’s Accreditation of Colleges of Osteopathic Medicine: COM New & Developing Accreditation Standards, effective July 1, 2017 (see Exhibit #6) and its most recent Accreditation of Colleges of Osteopathic Medicine: COCA Policies and Procedures, effective August 28, 2017 (see Exhibit #8); page 29 of this manual states that “[i]f the COM has not been able to proceed to Accreditation status within five years of the granting of Pre-Accreditation Status, the Pre-Accreditation Status will be withdrawn,” which is aligned with regulations. The agency’s use of “pre-accreditation” now reflects the Department’s intent of the phrase without any other references to “provisional accreditation”. Also, under its revised policy, the agency has had an opportunity to award the proposed Idaho College of Osteopathic Medicine “pre-accreditation status” (see Exhibit #159).




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;


Previous Issue: The agency still has not submitted the completed mid-cycle review and self-study for the same institution for review of their use as described in the COM accreditation standards and the criteria for this section. Discussion: The agency has made great strides, but still remains out of compliance with this criterion. As requested by the Department, the agency has now submitted a completed mid-cycle review and a self-study from the same institution (i.e., Lake Erie College of Osteopathic Medicine [LECOM]) [see Exhibit #s 105-118]; and it has submitted other similar documents from its reviews of Nova Southeastern University College of Osteopathic Medicine (NSU-COM) [see Exhibit #s 119-133] and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90] to illustrate that its review procedures for these reports are consistent with what is required for this section’s criteria. However, the agency also provided a copy of its COCA Annual Report/Mid-cycle Report Review Procedures (see Exhibit #47), and the document still refers to “provisional accreditation”, which is inaccurate now that the agency has eliminated the term from its Accreditation of Colleges of Osteopathic Medicine: COM New & Developing Accreditation Standards, effective July 1, 2017 (see Exhibit #6) and its most recent Accreditation of Colleges of Osteopathic Medicine: COCA Policies and Procedures, effective August 28, 2017 (see Exhibit #8). The agency must revise its COCA Annual Report/Mid-cycle Report Review Procedures so that it aligns with its current policy with regard to the elimination of any references to “provisional accreditation”. The agency also provided a copy of its Instructions for the COCA Mid-Cycle Report (see Exhibit #48) to help illustrate compliance with this criterion.




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.


Previous Issue: The agency must provide the (1) mid-cycle review documents for CUSOM and the (2) annual report documents for LMU DCOM along (3) with both COMs commission decision letters for review and adherence to the criteria for this section. Discussion: The agency is now compliant with this criterion, although it used evidence from two different institutions that it accredits in lieu of documentation from, as requested by the Department, the two institutions that it initially provided to support compliance with this criterion. Because the agency accredits numerous institutions across the nation that must have had complete accreditation cycles to date, the Department finds it perplexing that the agency would initially select Lincoln Memorial University DeBusk College of Osteopathic Medicine (LMU-DCOM) and Campbell University Jerry M. Wallace School of Osteopathic Medicine (CUSOM) to support this particular criterion given that neither has sufficient documentation that is reflective of a complete accreditation cycle. Rather than providing annual report documentation from LMU-DCOM, the agency offered documents for Lake Erie College of Osteopathic Medicine (LECOM) instead (see Exhibit #s 105-118). At the time of submission for re-recognition, the agency asserts that the LMU-DCOM self-study was unavailable; that it would undergo a comprehensive review this calendar year (2018); and that its self-study is due to the agency in early spring of 2018. Consequently, a complete set of current accreditation documents was not available for LMU-DCOM. However, documentation from LECOM (the institutional replacement) demonstrates a full cycle of accreditation activity, including requests for additional information related to annual reporting and mid-cycle reporting, and a commission decision letter (see Exhibit #111). Similarly, the agency provided documentation for a full accreditation cycle for Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) [see Exhibit #s 68-90] in place of the Department’s request for mid-cycle review documentation from CUSOM. Because CUSOM achieved initial accreditation status in April of 2017, it has not been subject to annual reporting and mid-cycle reporting just yet. Documentation from MWU-CCOM (the institutional replacement) demonstrates a full cycle of accreditation activity, including requests for additional information related to annual reporting and mid-cycle reporting, and a commission decision letter (see Exhibit #72). The agency also submitted an accreditation cycle for Nova Southeastern University College of Osteopathic Medicine (NSU-COM) to help support the case for compliance with this criterion. In addition, the agency also explained the role of its annual report in the accreditation process, including how it uses the financial and student achievement data collected by the American Osteopathic Association (AOA) and the American Association of Colleges of Osteopathic Medicine (AACOM) in its review of Colleges of Osteopathic Medicine (COMs). Moreover, the agency pointed out that its COM Continuing Accreditation Standards, effective July 1, 2017 (see Exhibit #7)—CORE Element 11.5: Program and Student Outcomes—Annual Data and Mid-Cycle Update Reports—requires COMs with accreditation status to submit specified annual and mid-cycle reports or risk a change in accreditation status if it fails to submit these reports.




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.


Previous Issue: It was unclear to the Department what enforcement timelines are being adhered to by the COM while correcting their adverse action(s) based upon the agency standards, policies, procedures and the Department’s requirements for this criterion. The agency provided a warning status notification from a Commission meeting as evidence, but did not submit subsequent action as evidence. The full cycle of the accreditation action (notice of deficiency, response, final commission action, etc.) must be provided in order for Department staff to ascertain if the enforcement timelines required by this criterion are being applied appropriately. Discussion: The agency has now described its enforcement timeline and provided adequate evidence supporting its full accreditation cycle (both new and continuing) to illustrate compliance with this section. After the agency’s Commission meetings, it notifies COMs of actions that were taken related to progress reports, self-studies, site visit reports, etc. Any accreditation decisions are compiled into a final action letter, which each COM receives within 30 days of the agency Commission meeting (per Department regulations). These letters include standards that have been met and unmet. For standards that have not been met, the agency directs each COM to monitor them with the goal of reaching compliance. The agency monitoring is done through required progress reports that are submitted by each COM 30 days before the following agency Commission meeting, typically March 1, July 1, and November 1. The agency also might direct focused site visits or other actions in addition to requiring a progress report. The agency notifies the Department, the State, and Regional/Institutional accreditors and makes all accreditation actions public within 30 days at its web site link: http://osteopathic.org/inside-aoa/accreditation/COM-accreditation/Pages/coca-final-actions.aspx. This process is explained in the agency’s Accreditation of Colleges of Osteopathic Medicine: COCA Policies and Procedures, effective August 28, 2017 (see Exhibit #8; specifically page 52 that illustrates alignment with 602.20(a)). Also, the agency has provided more than a lone warning status notification letter for LUCOM that emerged from one of its Commission meetings. Now, the agency has provided more documentation, including a notice of deficiency (i.e., “final action letter” in this case), the COM response, and the final action taken after the response (see Exhibit #s 133-135). The agency also provided accreditation cycle documentation for Alabama College of Osteopathic Medicine (ACOM) [see Exhibit #s 39, 40, & 49-67]; and Midwestern University/Chicago College of Osteopathic Medicine (MWU-CCOM) mid-cycle review progress reports [see Exhibit #s 68-90] in order to support compliance with this criterion.




602.26(b) Notifications: Negative Decisions

(b) Provides written notice of the following types of decisions to the Secretary, the appropriate State licensing or authorizing agency, and the appropriate accrediting agencies at the same time it notifies the institution or program of the decision, but no later than 30 days after it reaches the decision:

(1) A final decision to place an institution or program on probation or an equivalent status.

(2) A final decision to deny, withdraw, suspend, revoke, or terminate the accreditation or preaccreditation of an institution or program;

(3) A final decision to take any other adverse action, as defined by the agency, not listed in paragraph (b)(2) of this section;


Previous Issue: The agency was found noncompliant for keeping confidential and not informing the Department when it placed an institution on “warning”; the agency pledged to revise its policies and procedures to adhere to Department requirements under this criterion. Discussion: The agency has revised its policies and procedures and is now compliant with this criterion. Specifically, the agency has “revised its policies regarding reporting and public notice to comply with the Department’s regulations”. This change is reflected in the agency’s Accreditation of Colleges of Osteopathic Medicine: COCA Policies and Procedures, effective August 28, 2017 (see Exhibit #8, page 23); the manual states that the agency “will notify the Secretary of USDE, the relevant state medical licensing boards, the relevant regional (institutional) accreditation body(ies), and the public of actions affecting accreditation status taken at a COCA meeting within 30 days of the meeting, including the decision to award initial accreditation or to renew a COM’s accreditation status.” The agency has had no occasion to report any adverse accreditation decision to the Department to date; however, the agency has reported an adverse decision regarding a substantive change request involving Lake Erie College of Osteopathic Medicine (LECOM) [see Exhibit #s 105-118], and it provided a copy of that decision directly to the Department and posted the decision on its own website: http://osteopathic.org/inside-aoa/accreditation/COM-accreditation/Pages/coca-final-actions.aspx.




Part III: Third Party Comments


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