Opportunity to Comment on Change to Policy #14

The Board of Commissioners approved a revision to POLICY #14 REPORTING SUBSTANTIVE CHANGES. Pursuant to Commission Policy #11, proposed policy changes are submitted to accredited programs for review and comment prior to implementation.
 
Please provide any comments by email to Yovanka Heyburn at yheyburn@nlnac.org no later than April 25, 2013. The Commissioners will consider these comments prior to implementation of the policy.
 
Thank you for reviewing this policy change. We appreciate your interest and support of the accreditation process.
 


POLICY #14
REPORTING SUBSTANTIVE CHANGES
 


It is the responsibility of each program to notify the National League for Nursing Accrediting Commission of major changes to ensure maintenance of accreditation status and protection of students. Failure to report changes places the accreditation status of the program in jeopardy.

The NLNAC reserves the right to reconsider the accreditation status of a nursing program at any time. Status change actions that may be taken by the Board of Commissioners include, but are not limited to, the following:

The NLNAC Board of Commissioners may also take action to require formal monitoring of a program due to non-compliance with any Accreditation Standard(s).

SUBSTANTIVE CHANGE

Planned Change

Any program proposing a planned substantive change in the ownership or form of control, mission, program offerings, curriculum, credentials conferred, length of program, method of delivery, relocation, or establishment of an additional location, or other planned changes as identified must report it to the NLNAC and obtain approval of the substantive change prior to implementation. The process must be followed immediately after the proposed change has been approved internally by the governing organization but no later than four months before the planned implementation date. Accompanying this notification, the program must include a detailed report for review that identifies the change, provides the rationale for the change, and addresses each of the NLNAC Standards and Criteria in accordance with the Guidelines for the Preparation and Submission of Planned and Unplanned Substantive Change Reports.

Programs that were granted Continuing Accreditation with Conditions or Warning by the NLNAC Board of Commissioners as a result of the last accreditation review may not implement planned substantive changes until the period of Conditions or Warning has been resolved. Exceptions may be made for substantive changes deemed necessary to ensure the program’s compliance with the NLNAC Accreditation Standards found to be in non-compliance. For example, a program may implement changes in curriculum to address non-compliance with Standard 4 Curriculum. However, a program may not increase student enrollment; add additional program options; add additional teaching locations; implement distance education; or add additional program types until the program has been granted Continuing Accreditation by the NLNAC Board of Commissioners.

Unplanned Change

Substantive changes requiring immediate notification of the NLNAC include: change in State Board of Nursing approval status; change in accreditation status of the governing organization; decline in program outcomes including licensure or certification examination pass rates, job placement rates, job satisfaction, or program completion rates; a default rate in student loan program that exceeds the regulation; identified fraud related to Title IV participation; or any communication related to an adverse federal action.

As with planned change, a report addressing unplanned changes must also be submitted to the NLNAC in accordance with the Guidelines for the Preparation and Submission of Planned and Unplanned Substantive Change Reports.

Minor Changes

If a program questions whether a change is substantive or minor, it should seek assistance from an NLNAC professional staff member.

Guidelines for the Preparation and Submission of Planned and Unplanned Substantive Change Reports are available at www.nlnac.org.

Planned Substantive Change – Notification Required 4 Months Prior to Implementation

Usual Review Process

Change in ownership, legal status, or form of control

Focused Visit required within six months after the change takes place
Commission Approval

Change in mission or objectives

Staff review/Focused Visit as indicated
Commission Approval

Implementation of distance education
(see Policy #15)

Staff review/Focused Visit as indicated

If NLNAC is the program’s Title IV gatekeeper, the focused visit is mandatory.

Commission Approval

Addition of courses or programs that represent a significant departure from existing offerings of educational programs or method of delivery

Staff review/Focused Visit as indicated

If NLNAC is the program’s Title IV gatekeeper, the focused visit is mandatory.

Commission Approval

Addition of programs of study at a degree or credential level different from that which is included in the nursing education unit’s current accreditation

Staff review/Focused Visit as indicated

Commission Approval

Change in length of program in relation to program and credentials (degree or certificate)

Staff review/Focused Visit as indicated

Commission Approval

Change in enrollment by headcount (greater than or equal to 25%) for each program offered in the nursing education unit

Staff review/Focused Visit as indicated

Commission Approval

Change in enrollment by headcount (greater than or equal to 50%) in the governing organization in one academic year

Staff review/Focused Visit as indicated

Commission Approval

Changes in method of academic measurements (clock or credit), or change in the number of clock or credit hours

Staff review/Focused Visit as indicated

Commission Approval

Relocation or establishment of an additional location

Staff review/Focused Visit as indicated

Commission Approval

The accreditation status of the program is not extended to an additional location until an accreditation decision is made by the NLNAC Board of Commissioners following the focused visit.

If NLNAC is the program’s Title IV gatekeeper, the focused visit is mandatory.

Acquisition of any other program or location of another governing organization

Staff review/Focused Visit as indicated

Commission Approval

Addition of a permanent location at a site at which the governing organization is conducting a teach-out for students of another governing organization that has ceased operating before all students have completed the program of study

Staff review/Focused Visit as indicated

Commission Approval

Entering into a contract under which an institution or organization not certified to participate in Title IV, HEA programs offers more than 25% of one or more of the accredited institution’s educational programs

Staff review/Focused Visit as indicated

Commission Approval

 

Unplanned Substantive Changes – Notification Required Immediately

Usual Review Process

Change in State Board of Nursing and/or state regulatory agency approval status (see Policy # 17)

Submission of all reports required by State Board of Nursing and/or state regulatory agency and copies of all correspondence from/to the agency regarding approval status; review of rationale for adverse action to determine need for further monitoring, possible change in accreditation status

Staff review/Focused Visit as indicated

Commission Approval

Adverse action by appropriate institutional accrediting agency (see Policy #18)

Review of rationale for adverse action to determine need for further monitoring

Staff review/Focused Visit as indicated

Commission Approval

Decline in program outcomes including performance on licensure or certifying examinations, program completion rates, program satisfaction, and/or employment rates 

Submission of a report addressing factors that resulted in the decline and the strategies developed to address the change; any reports and related correspondence required by the state regulatory agency

Staff review/Focused Visit as indicated

Commission Approval

Title IV Participant Compliance:

  • Default rate in student loan program that exceeds threshold set by legislation, regulation, and policies
  • Fraud and abuse
  • Adverse action following financial or compliance audits, program review, or other information that becomes available
  • Entering into a contract with an educational organization that is not eligible to participate in Title IV

Submission of copies of all correspondence to/from the Department of Education regarding adverse action, rationale for adverse action, and program’s plan for addressing the adverse action.

Staff Recommendation/Focused Visit as indicated

If NLNAC is the program’s Title IV gatekeeper, the focused visit is mandatory.

The U.S. Department of Education is notified.

 

Other Substantive Changes – Notification
Required Immediately

Usual Process

Any significant noncompliance with the credit hour policies of either the NLNAC or the governing organization’s accrediting agency

The NLNAC will take action if the noncompliance is systemic and/or if there is significant noncompliance involving one or more programs at the governing organization.

The U.S. Department of Education is notified within 30 days of confirmation.

Change of Nurse Administrator

Submission of official written notification by the governing organization of the change and CV/Resume of new administrator required

Staff review and acknowledgment

Change in organizational structure of the nursing education unit

Staff Recommendation/Focused Visit as indicated

Program closing

See Policy #16