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title: "November 10, 2023 - Substantive Change Actions"
canonical: "https://resources.acenursing.org/space/CA/4015783958/November%2010%2C%202023%20-%20Substantive%20Change%20Actions"
format: markdown
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# <span style="color: #333333">Notification of Substantive Change Actions November 10, 2023</span>

## <span style="color: #333333">**Board of Commissioners Actions**</span>

<span style="color: #333333">The following publicly available information is provided by the Accreditation Commission for Education in Nursing (ACEN) concerning actions taken on November 10, 2023, by the ACEN Board of Commissioners related to substantive changes. Commission staff will not speculate on what decision might be made by the ACEN Board of Commissioners the next time a program is reviewed. For additional information regarding ACEN accreditation process, access the Accreditation Manual.</span>

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<span style="color: #333333">**The Board of Commissioners approved the **</span><u><span style="color: #333399">**substantive change report**</span></u><span style="color: #333399">** **</span><span style="color: #333333">**for the following programs:**</span>

- **Alaska Pacific University **<span style="color: #333333">(Associate) Anchorage, Alaska, related to an increase in program enrollment of 50% or greater.</span>
- **Colorado Mountain College **<span style="color: #333333">(Baccalaureate) Glenwood Springs, Colorado, related to the implementation of a generic BSN program option.</span>
- **Eastern New Mexico University **<span style="color: #333333">(Baccalaureate) Portales, New Mexico, related to an increase in program enrollment of 50% or greater.</span>
- **Hackensack Meridian Health, Inc., JFK Medical Center Muhlenberg Harold B. and Dorothy A. Snyder School of Nursing **<span style="color: #333333">(Diploma) Metuchen, New Jersey, related to curriculum revisions of 50% or greater.</span>
- **International College of Health Sciences **<span style="color: #333333">(Baccalaureate) Boynton Beach, Florida, related to the implementation of a pre-licensure BSN program option.</span>
- **Missouri Southern State University **<span style="color: #333333">(Baccalaureate) Joplin, Missouri, related to the implementation of distance education of 50% or greater and curriculum revisions of 50% or greater.</span>
- **New England Institute of Technology **<span style="color: #333333">(Practical) East Greenwich, Rhode Island, related to a decrease in clinical clock hours.</span>
- **New England Institute of Technology **<span style="color: #333333">(Practical) East Greenwich, Rhode Island, , related to an increase in program enrollment of 50% or greater.</span>
- **Oconee Fall Line Technical College **<span style="color: #333333">(Associate) Sandersville, Georgia, related to the implementation of the new Dublin off-campus instructional site and associate degree traditional program option, which will occur January 1, 2024.</span>

- **Oklahoma City University **<span style="color: #333333">(Clinical Doctorate) Oklahoma City, Oklahoma, related to the implementation of a DNP Nurse Educator program option.</span>

<span style="color: #333333">**The Board of Commissioners approved the **</span><u><span style="color: #333399">**substantive change report**</span></u><span style="color: #333399">** **</span><span style="color: #333333">**and authorized a **</span><u><span style="color: #333399">**focused visit**</span></u><span style="color: #333399">** **</span><span style="color: #333333">**for the following programs:**</span>

- <span style="color: #333333">**None**</span>

<span style="color: #333333">**The Board of Commissioners approved the **</span><u><span style="color: #333399">**substantive change report**</span></u><span style="color: #333399">** **</span><span style="color: #333333">**and requested a written report about the status of the implementation of the substantive change for the following programs:**</span>

- <span style="color: #333333">**None**</span>

<span style="color: #333333">**The Board of Commissioners approved the **</span><u><span style="color: #333399">**substantive change report**</span></u><span style="color: #333399">** **</span><span style="color: #333333">**and removed the requirement for a **</span><u><span style="color: #333399">**focused visit**</span></u><span style="color: #333399">** **</span><span style="color: #333333">**for the following programs:**</span>

- <span style="color: #333333">**None**</span>

<span style="color: #333333">**The Board of Commissioners denied the **</span><u><span style="color: #333399">**substantive change report**</span></u><span style="color: #333399">** **</span><span style="color: #333333">**and authorized a **</span><u><span style="color: #333399">**focused visit**</span></u><span style="color: #333399">** **</span>**for the following programs:**

- <span style="color: #333333">**None**</span>

<span style="color: #333333">**The Board of Commissioners denied the **</span><u><span style="color: #333399">**substantive change report**</span></u><span style="color: #333399">** **</span><span style="color: #333333">**for the following programs:**</span>

- <span style="color: #333333">**None**</span>

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# <span style="color: #333333">Definitions</span>

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<span style="color: #333333">**Continuing Accreditation: **</span><span style="color: #333333">A determination by the ACEN Board of Commissioners that a nursing program is in compliance with all Accreditation Standards.</span>

<span style="color: #333333">**Continuing Accreditation with Conditions: **</span><span style="color: #333333">A measure imposed by the ACEN Board of Commissioners following the determination of non-compliance with one (1) or two (2) Accreditation Standards. Next review and follow-up action(s) are determined by the Board of Commissioners.</span>

<span style="color: #333333">**Continuing Accreditation with Warning: **</span><span style="color: #333333">A measure imposed by the ACEN Board of Commissioners following the determination of non-compliance with three (3) or more Accreditation Standards. Next review and follow-up action(s) are determined by the Board of Commissioners.</span>

<span style="color: #333333">**Continuing Accreditation for Good Cause: **</span><span style="color: #333333">A measure imposed by the ACEN Board of Commissioners following the determination that a nursing program has not remedied deficiencies at the conclusion of its maximum monitoring period and the program has (a) has demonstrated significant recent accomplishments in addressing ; (b) has documented that it has the potential to remedy all deficiencies within the extended period as defined by the Commission; that is, that the program provides evidence which makes it reasonable for the Commission to determine it will remedy all deficiencies within the extended time defined by the Commission; and (c) provides assurance to the Commission that it is not aware of any other reasons, other than those identified by the Commission, why the nursing program could not be continued for good cause.</span>

<span style="color: #333333">**Denied Initial Accreditation: **</span><span style="color: #333333">A determination by the ACEN Board of Commissioners that a nursing program is in non-compliance with one or more Accreditation Standard.</span>

<span style="color: #333333">**Denied Continuing Accreditation: **</span><span style="color: #333333">A determination by the ACEN Board of Commissioners that a nursing program on conditions, warning, or for good cause is found to be in continued non-compliance with any Accreditation Standard. Thereafter the nursing program is removed from the listings of accredited programs.</span>

<span style="color: #333333">**Focused Visit: **</span><span style="color: #333333">A site visit authorized by the ACEN Board of Commissioners to review significant accreditation-related information disclosed about a program as a result of:</span>

<span style="color: #333333">A substantive change;</span>

<span style="color: #333333">Information revealed about a program between periods of scheduled review;</span>

<span style="color: #333333">Information received from the governing organization’s accrediting body related to an adverse action;</span>

<span style="color: #333333">Information received from the program’s state regulatory agency for nursing related to a change in its status;</span>

<span style="color: #333333">Information revealed by a program during the Evaluation Review Panel process;</span>

<span style="color: #333333">Information received from the U.S. Department of Education regarding a program’s compliance responsibilities under Title IV of the Higher Education Act such as information related to a program’s most recent student loan default rates, the results of financial or compliance audits, program reviews, and any other information that may be provided by the U.S. Department of Education.</span>

<span style="color: #333333">**Follow-up Report: **</span><span style="color: #333333">A report prepared by a program addressing the Standard(s) for which the nursing program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.</span>

<span style="color: #333333">**Initial Accreditation: **</span><span style="color: #333333">A determination by the ACEN Board of Commissioners that a nursing program is in compliance with all Accreditation Standards.</span>

<span style="color: #333333">**Remove the Conditions Status and Grant Continuing Accreditation: **</span><span style="color: #333333">A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standard(s) that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.</span>

<span style="color: #333333">**Remove the for Good Cause Status and Grant Continuing Accreditation: **</span><span style="color: #333333">A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standards that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.</span>

<span style="color: #333333">**Remove the Warning Status and Grant Continuing Accreditation: **</span><span style="color: #333333">A determination by the ACEN Board of Commissioners that a nursing program is in compliance with the Accreditation Standard(s) that the program was found to be in non-compliance during the program’s previous review by the ACEN Board of Commissioners.</span>

<span style="color: #333333">**Standard:**</span>

<span style="color: #333333">**See ACEN 2017 Standards and Criteria**</span>

<span style="color: #333333">**See ACEN 2023 Standards and Criteria**</span>

<span style="color: #333333">**Substantive Change Report: **</span><span style="color: #333333">A report submitted by an accredited program informing the ACEN of a significant modification or expansion of the nature and scope of a nursing program and/or nursing education unit.</span>