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title: "March 4, 2022 -Substantive Change Actions"
canonical: "https://resources.acenursing.org/space/CA/4016341048/March%204%2C%202022%20-Substantive%20Change%20Actions"
format: markdown
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# <span style="color: #333333">Notification of Substantive Change Actions March 4, 2022 </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 March 4, 2022, by the ACEN Board of Commissioners related to substantive changes.</span>

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

<span style="color: #333333">Standards: 2017 Standards and Criteria</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">**for the following programs:**</span>

- **Albany State University **<span style="color: #333333">(Baccalaureate) Albany, GA related to the implementation of a consortia relationship.</span>
- **Berkshire Community College **<span style="color: #333333">(Associate) Pittsfield, MA related to an increase in program enrollment of 50% or greater.</span>
- **Carolinas College of Health Sciences **<span style="color: #333333">(Associate) Charlotte, NC related to the implementation of distance education of 50% or greater.</span>
- **Colorado Mesa University **<span style="color: #333333">(Associate) Grand Junction, CO related to a decline in licensure examination pass rates.</span>
- **New Mexico State University – Carlsbad **<span style="color: #333333">(Associate) Carlsbad, NM related to a change in ownership.</span>
- **University of Pikeville **<span style="color: #333333">(Baccalaureate) Pikeville, KY related to an increase in program enrollment of 50% or greater.</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>

- **Galen College of Nursing – San Antonio **<span style="color: #333333">(Associate) San Antonio, TX related to the implementation of the new Austin off-campus instructional site.</span>
- **Grantham University **<span style="color: #333333">(Baccalaureate) Lenexa, KS related to a change in ownership.</span>

- **Herzing University – Akron **<span style="color: #333333">(Associate) Akron, OH related to a decline in licensure examination pass rate.</span>
- **Langston University **<span style="color: #333333">(Baccalaureate) Langston, OK related to a decline in licensure examination pass rate.</span>
- **Salish Kootenai College **<span style="color: #333333">(Baccalaureate) Pablo, MT College related non-compliance with Criterion 1.5 following a change in nurse administrator.</span>
- **Seminole State College **<span style="color: #333333">(Associate) Seminole, OK related to a decline in licensure examination pass rate.</span>
- **St. Catherine University **<span style="color: #333333">(Clinical Doctorate) Saint Paul, MN related the implementation of the Psychiatric-Mental Health Nurse Practitioner (PMHNP) certificate 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 requested a written report about the status of the implementation of the substantive change for the following programs:**</span>

- **Iowa Wesleyan University **<span style="color: #333333">(Baccalaureate) Mount Pleasant, IA related to a decline in licensure examination pass rate.</span>
- **Lehigh Valley Health Network **<span style="color: #333333">(Diploma) Pottsville, PA related to a decline in licensure examination pass rate.</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>

**The Board of Commissioners denied the **<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>

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

- <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</span>

<span style="color: #333333">related to an adverse action;</span>

- <span style="color: #333333">Information received from the program’s state regulatory agency for nursing</span>

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