CAPTE: On-site Reviewer Training Module

2. CAPTE: On-site Reviewer Training Module 9 – CAPTE Decisions

3. Objectives • Identify the document CAPTE uses to communicate the outcome of a program review • Identify the difference between conditional compliance and non-compliance • Match the accreditation status decisions with possible rationales for granting the status • Describe the effect on students if accreditation is withdrawn

4. Summary of Action (SOA) Within 30 days of CAPTE’s review, the program is provided with a written report called a Summary of Action or SOA. It is sent to the program director and institutional administrators Summary ofAction Provides the accreditation decision, the justification for the decision and information the program may need to address in future Compliance Reports

5. CAPTE’s Process to Develop a SOA • Prior to CAPTE meeting, assigned reviewers • Review of all program materials • Write draft Summary of Action • Contact program director • Contact team leader if needed • At CAPTE meeting, reviewers • Present draft SOA to Panel • Finalize SOA • Present to full Commission • Staff edit and sends SOA to program The accreditation decision made by CAPTE is based on all the materials available at the time it is reviewing the program. This can include: the Self-study Report; the Visit Report; the response of the institution to the Visit Report; additional materials, if any have been provided by the program; and, when requested, Compliance Reports. Eligible written third-party comments may also be used if they have been submitted. As Commissioners review these materials, they may solicit clarifications and updates from the program director and/or the team leader. Each program is assigned primary and secondary CAPTE reviewers who are responsible for writing the SOA and presenting it to the appropriate CAPTE panel. The Panel discusses the areas believed to be out of compliance and determines the accreditation status decision that is then brought to the full Commission for its consideration.

6. Summary of Action Includes • Decision on AccreditationStatus • NextAction • StudentAchievement • Areas of Non-compliance (ifany) • Areas of Conditional compliance (ifany) • Consultative comments (ifany) • Commendations (ifany) • Every SOA includes the decision on accreditation status and identifies the next action that the program needs to take. The next action can be a progress report that is due in 6 or 12 months. When there are no areas that are out of compliance, the next action is the a Self-study Report and on-site visit. • For the first SOA after an on-site visit, there is a statement with respect to student achievement and the success of the program in meeting its mission. • The SOA also identifies the elements that are out of compliance. These citations are broken down into 2 areas: areas of non-compliance and areas of conditional compliance. The next slide discusses the difference between these two. • The SOA can also contain consultative comments if CAPTE wants to give advice about how improvements could be made. Programs are not expected to respond to consultative comments in a compliance report. Commendations are used when there are aspects of the program that CAPTE found to be well beyond compliant with the Standards and Required Elements. 4 6 2 3 5 7 1

7. Citations The SOA contains a citation for each element found out of compliance. The citation identifies what CAPTE considers problematic and requests additional information in the form of a compliance report. Citations are classified as conditional compliance, when most but not all elements are in place, or as non-compliance, when a substantial portion of the elements are not in place. The US Department of Education requires there be a limitation for a program to be out of compliance with a given element, unless the program can demonstrate a good faith effort to come into compliance. CAPTE has set that limit at 2 years. Conditional Compliance Non-compliance There is substantial portion, but not all, of elements necessary to meet the Require Element Does not have substantial portion of elements necessary to meet the Require Element

8. Accreditation Decisions The accreditation status awarded to each program is based on the extent to which the program complies with the current Standards and Required Elements. There are three status classifications that describe entry-level education programs; these are accreditation, probationary accreditation, and non-accreditation. CAPTE also has the option to defer action until the next scheduled meeting if it finds it necessary to postpone determining an accreditation status. 1 2 3 5 6 4 Non-Accreditation: Accreditation Withheld Non-Accreditation: Accreditation Withdrawn Probationary Accreditation Accreditation Defer Action Defer Action: Show Cause

9. Status: Accreditation • Substantial Compliance • Programs that are found to be in substantial compliance with the Standards and Required Elements are granted Accreditation status. If there are elements that are found to be out of compliance, programs are asked to submit written evidence, in the form of a Compliance Report, of the actions taken to bring the program into compliance • Granted for 10 years (continuing) or 5 years (initial) • However, CAPTE always has the right to shorten these time periods should it be deemed necessary • May need to submit Compliance Reports • 2 year limit to be out of compliance

10. Status: Probationary Accreditation • Signals that a program’s accreditation is in jeopardy • Cannot exceed the length of the program, or 2 years, whichever is shorter • Considered an accredited status by CAPTE and licensing boards • Institution is required to notify all enrolled and prospective students that future accreditation is in jeopardy Probationary Accreditation is granted when the program has been determined to have significant areas that are out of compliance, such that there is reason to question the institution’s ability to offer an acceptable educational experience and to generate acceptable outcomes. However, it may also be granted when CAPTE’s citations have not been addressed in a satisfactory and timely manner; when the institution has been placed on Probationary Accreditation by its institutional accrediting agency; or, when the state regulatory body has withdrawn legal authority to provide education. Probationary Accreditation signals that the program’s accreditation is in jeopardy. CAPTE may act to withdraw accreditation status at any time if CAPTE receives information that provides clear evidence that circumstances exist which further jeopardize the capability of the sponsoring institution to provide an acceptable educational experience for the physical therapy students.

11. Status: Withhold Accreditation Restricted to programs initially applying for accreditation • Awarded when • Vital resources necessary for the success of the program are missing; or • Areas out of compliance indicate unable to offer acceptable learning experiences • Institution required to notify all enrolled students and those seeking admission that accreditation by CAPTE has been withheld. If CAPTE determines that a program applying for initial accreditation is significantly out of compliance, it will grant Withhold Accreditation. Since this is considered an adverse action, written notification of this action includes information about the reconsideration and appeal procedures available to the program.

12. Status: Withdraw Accreditation Awarded when status is Probationary Accreditation and sufficient progress has not been made • Awarded without Probationary Accreditation if: • Requested by the sponsoring institution • There has not been a qualified program director for more than 2 years • Program fails to pay annual accreditation fees within the allotted time. • Institution required to notify all enrolled and prospective students Typically CAPTE does not withdraw accreditation unless a program has first been put on probation, except if it has been requested to do so by the institution. Although programs typically have 2 years to come off of probation, CAPTE does not have to wait that long to withdraw accreditation if it believes circumstances warrant doing so. As with other adverse decisions, the institution is required to notify all students enrolled in the physical therapy program, and those seeking admission, that CAPTE has acted to withdraw accreditation. The institution must provide information to the students about its plan to address the accreditation decision. The institution is also required to develop a teach-out plan for students enrolled in the program and provide a copy to CAPTE. The effects of Withdraw Accreditation on current students will be discussed later.

13. Status: Defer Action • Used only with established programs • Granted when: • CAPTE has conflicting or insufficient information • An unstable situation exists and resolution is likely by next regularly scheduled CAPTE meeting When Defer Action is used, the program is asked for additional information, in the form of a Compliance Report, for consideration at the next CAPTE meeting. The program’s accreditation status will remain unchanged until the next meeting, when CAPTE must make an accreditation decision.

14. Status: Show Cause • Used only with established programs • Provides warning • Granted when there is clear evidence of circumstances that jeopardize the capability to provide acceptable educational experiences • CAPTE must take an accreditation action at its next regularly scheduled meeting Show Cause serves as a warning to programs that CAPTE is considering probationary accreditation if evidence of improvement is not submitted for review at the next scheduled CAPTE meeting. When a program’s current status is Probationary Accreditation, Show Cause should be considered a warning of impending withdrawal of accreditation if evidence of improvement is not submitted for review at the next meeting.The specific concerns that led CAPTE to take this action are included in the Summary of Action. The program’s accreditation status will remain unchanged until action is taken at the next meeting.

15. Reconsiderations and Appeals Reconsideration • Appeal • Special Panelappointed CAPTE’s rules provide programs with an opportunity for due process if they do not agree with CAPTE’s decisions.A request for reconsideration asks CAPTE to conduct its own review of its accreditation status decision for the purpose of determining whether it committed any error or made any oversight or omission in its decision-making process or whether matters have arisen since the on-site visit or CAPTE's decision which require relief from the Commission's original decision. If CAPTE does not overturn its original decision on reconsideration, an institution can ask the Chair of CAPTE to appoint an Appeal Panel to review the decision of CAPTE. The Appeal Panel is appointed from a pool of experienced on-site reviewers in order to ensure that those familiar with the process are involved. • CAPTE reviews itsdecision • No new information can be presented • New information can be provided by the program • Decision isfinal IMPORTANT! Reconsiderations MUST be exhausted before Appeals will be granted On appeal, the institution has the burden of proving that CAPTE's status decision was not supported by substantial evidence on the record, was otherwise arbitrary and capricious, or was an abuse of the Commission's discretion. Only materials that were available to CAPTE at the time of the reconsideration hearing can be used by the Appeal Panel. Since the Appeal Panel has no authority to grant accreditation, if the Appeal Panel agrees with the institution, the decision is remanded back to CAPTE to change its decision. CAPTE’s rules require it to uphold the Appeal Panel’s decision.

16. Decisions Eligible for Reconsideration • Only decisions to withhold or withdraw accreditation are eligible for reconsideration • Neither Probationary Accreditation or shortening the accreditation cycle are defined as adverse decisions • The institution has the ability to address areas of concern through a Compliance Report

17. Reconsideration of Candidacy Decisions Pre-accredited programs seeking candidacy status from CAPTE can be denied Candidate for Accreditation status. The program then has the option to request reconsideration of the decision. A reconsideration hearing is held at a regularly scheduled CAPTE meeting and the institution has the opportunity to send representatives. Based on the evidence provided at the reconsideration hearing, CAPTE either reaffirms its previous decision to withhold or withdraw Candidacy or it reverses its decision and grants Candidacy. Reconsideration hearing CAPTE conducts hearing CAPTE either reaffirms or reversesdecision Note Part 13 of the Accreditation Handbook describes Reconsideration of Candidacy decisions

18. Accreditation Withheld: Effects on Students CAPTE makes initial accreditation decisions in the last semester of the charter class. Should a program have its accreditation withheld during this initial accreditation review, students in the charter class will not be considered to be graduates of an accredited program. CAPTE reserves the right not to make the decision retroactive to include the charter class in cases where there is serious concern about the academic preparation and/or clinical competence of the that cohort of students. If the decision to withhold accreditation is reversed on reconsideration or appeal, students in future classes will be considered graduates of an accredited program. Options Students in the charter class will not be considered to be graduates of an accredited program unless: And CAPTE makes decision retroactive to include the charter class CAPTE reserves the right not to make the decision retroactive The decision is reversed on reconsideration or on appeal Note Part 14 of the Accreditation Handbook describes Reconsideration processes for Accreditation Withheld

19. Accreditation Withdrawn: Effects on Students If the institution seeks reconsideration and is not successful, the reconsideration decision date becomes the effective date of the Accreditation Withdrawn status. If the institution chooses to Appeal, and the Appeal does not result in reversal of the adverse decision, the effective date remains the date established by the reconsideration decision. If seek reconsideration and is not successful, Accreditation Withdrawn status is not effective until reconsideration decision is rendered Only students in the final 12 months of the program will be considered graduates of an accredited program If institution seeks to Appeal and Appeal is not successful, effective date is date reconsideration decision was rendered Note Part15 of the Accreditation Handbook describes Appeal Processes When a program has its accreditation withdrawn, only those students in the final year of the program are considered to be graduates of an accredited program. However, they must successfully complete the program as originally scheduled.

20. Summary • Elements of a Summary of Action • Possible CAPTE Actions • Reconsideration and Appeals Process This module has provided an understanding of the different accreditation decisions that CAPTE can make and how the decision is communicated to programs through the Summary of Action. In addition, the due process options available to programs when CAPTE makes an adverse decision were reviewed.