5606 WITHDRAWAL OF ACCREDITATION OR REDUCTION TO CONDITIONAL STATUS

5606.1 The first year that the percentage of a program's first time NCLEX test takers passing the exam is more than five percent (5%) below the national norm:

(a) The Board shall send written notice to the program of the following:

(1) The program has failed to meet the requirements and standards of this chapter;

(2) The program may, at the Board's discretion, be placed on conditional accreditation status; and

(3) The Board or its designee may perform an announced or unannounced on-site visit to the facility and provide a report to the Board.

(b) The program's nurse administrator shall submit to the Board, within thirty (30) calendar days, from receipt of the Board's letter the following:

(1) A report that identifies the factors believed to have contributed to the unacceptable performance; and

(2) An action plan to correct the deficiencies, to be approved by the Board.

5606.2 The second successive year that the percentage of a program's first time NCLEX test takers passing the exam is not more than five percent (5%) below the national norm, or the first year that the percentage is more than fifteen percent (15%) below the national norm:

(a) The Board shall send written notice to the program of the following:

(1) The program has failed to meet the requirements and standards of this chapter;

(2) The program shall be placed on conditional accreditation status;

(3) The Board or its designee may perform an announced or unannounced on-site visit to the facility and provide a report to the Board; and

(4) The Board shall provide the program with a list of the deficiencies that must be corrected and designate a time period for the correction of the deficiencies.

(b) The program's nurse administrator shall submit to the Board, within a time period specified by the board, from receipt of the Board's letter the following:

(1) A report analyzing all aspects of the education program and identifying areas believed to be contributing to the unacceptable performance;

(2) An action plan to correct the deficiencies, to be approved by the Board; or

(3) Proof that the program has obtained the services of an outside consultant, to be approved by the Board.

5606.3 The NCLEX pass rate requirements of this chapter shall not apply to advanced practice nursing education programs.

5606.4 The Board may withdraw accreditation or reduce a program to conditional accreditation, at its discretion, for any of the following reasons:

(a) The Board has determined that a program has not met, maintained or will be unable to meet or maintain the requirements and standards of this chapter;

(b) The nursing program has failed to correct the deficiencies identified by the Board within the allotted time period;

(c) Failure to hire a nurse administrator who meets the qualifications of this chapter;

(d) Failure to hire faculty who meet the qualifications of this chapter;

(e) Noncompliance with the school's stated philosophy, program design, objectives or outcomes, or policies;

(f) Failure to implement the approved curriculum;

(g) Failure to maintain the required NCLEX pass rate for first-time test takers;

(h) Failure to maintain NLNAC accreditation, CCNE accreditation, or accreditation by other accrediting bodies approved by the Board;

(i) Failure to submit records and reports to the Board in a timely manner;

(j) Noncompliance with any of the regulations in this chapter; and

(k) Other activities or situations, as determined by the Board, that indicate a program is not meeting the legal requirements and standards of this chapter.

5606.5 If the Board reduces a program to conditional accreditation status, the Board shall:

(a) Notify the program that it has been reduced to conditional accreditation status and the reasons for the decision;

(b) Provide the program with a list of the deficiencies that must be corrected in order to achieve full accreditation status;

(c) Designate a time period, not to exceed two (2) years, for the correction of the deficiencies;

(d) Notify the program that if the identified deficiencies are not corrected within the designated time period, the Board may withdraw accreditation of the program; and

(e) Re-designate the accreditation status of the program on the Board's Internet website and annual publication list.

5606.6 Before the Board may withdraw accreditation of a program the Board shall:

(a) Issue a Notice of Intended Action to the program notifying the program that:

(1) The Board intends to withdraw accreditation of the program and the reasons for the action; and

1. (2) The program has a right to a hearing;
2. (b) Issue public notice that the Board intends to withdraw accreditation of the program. The notice shall be:
3. (1) Sent to the Education Licensure Commission; and
4. (2) Issued to the public in a manner, as determined by the Board, to provide adequate notice to the individuals that have an interest in the intended action; and
5. (c) Ensure that the program provides its current student population and applicants with immediate notice of the Board's intended action, which shall include mailings and public postings on the premises.5606.7 If requested by any student, the program shall provide its current student population with assistance for transferring to another nursing program.5606.8 After the Board has withdrawn accreditation of a program, the Board shall provide notice of the withdrawal to the Education Licensure Commission and the program shall not be permitted to operate a nursing education program in the District.5606.9 The Board may designate persons to conduct an unannounced visit to the facility to ensure that the program has not continued to operate the nursing program or admit students after the effective date of the accreditation withdrawal.5606.10 The effective date of the withdrawal of accreditation shall be the date the Board renders a final decision and the Board shall immediately issue public notice of the withdrawal of accreditation. The Board may, at its discretion, postpone the effective date of the withdrawal of accreditation until the end of a current semester, when it determines such to be in the best interests of the program's graduating class or students.5606.11 If the program appeals the Board's decision to the District of Columbia Court of Appeals, the effective date of the withdrawal of accreditation shall not be changed unless changed pursuant to an Order of the Court of Appeals.5606.12 Students enrolled in the program prior to, or up to, the effective date of the withdrawal of accreditation shall be allowed to transfer to another District of Columbia nursing program.5606.13 The program shall provide its current student population with information and assistance for transferring to another nursing program.5606.14 Within thirty (30) days after receipt of notice that accreditation has been withdrawn, the nurse administrator or owner of the program shall submit to the Board a written plan for termination of the program. The plan shall include:- (a) A plan for the transfer of students to other approved programs within a timeframe established by the Board; and
6. (b) A plan outlining the arrangements made for storage of the permanent records of the students, graduates, and faculty; and where and how they may be obtained.5606.15 Students graduating from the program prior to, or up to, the effective date of the withdrawal of accreditation shall be allowed to sit for the NCLEX in the District of Columbia and upon passing, be licensed in the District of Columbia.

5606.16 Students attending or graduating from a program after the effective date of the withdrawal of accreditation shall not be allowed to sit for the NCLEX in the District or to be licensed in the District.

5606.17 After accreditation has been withdrawn, the controlling institution or owner of the nursing school may apply to the Board for initial accreditation as a new program pursuant to § 560 1.

5606.18 If the name of the program is changed, the controlling institution or owner shall disclose in its proposal that the Board previously withdrew accreditation, and identify the name of the program under which it was previously operated.

5606.19 A program aggrieved by a final decision of the Board may appeal the decision to the District of Columbia Court of Appeals in accordance with the District of Columbia Administrative Procedure Act, D.C. Code §§ 2-501 et seq.

SOURCE: Final Rulemaking published at 51 DCR 7190 (July 23, 2004); as amended by Final Rulemaking published at 54 DCR 2116 (March 9, 2007).