201 KAR 20:360. Evaluation of prelicensure registered nurse and practical nurse programs.
RELATES TO: KRS 314.111
STATUTORY AUTHORITY: KRS 314.131(1)
NECESSITY, FUNCTION, AND CONFORMITY: KRS 314.131(1) authorizes the Board of Nursing to promulgate administrative regulations to implement KRS Chapter 314. KRS 314.111 requires nursing programs to be approved by the board. This administrative regulations establishes evaluative standards to assure that the programs of nursing provide the necessary instruction and services to prepare graduates for licensure eligibility as registered nurses or as practical nurses.
Section 1. Approval Status and Withdrawal of Approval. Approval status shall be based upon each program of nursing’s performance and demonstrated compliance with 201 KAR 20:260 through 20:360.
(1) Developmental approval shall be the designation granted to a proposed program of nursing to continue development of plans for program implementation.
(2) Initial approval shall be the designation granted to a new program of nursing upon admission of the first class, if provided the date of enrollment is within eighteen (18) months of board approval of the proposal. During the period of initial approval, reports documenting implementation of the proposal shall be submitted on a quarterly basis.
(3) Full approval shall be the designation granted to a program of nursing that has implemented the proposal and that continues to meet the standards of 201 KAR 20:260 through 20:360.
(4) Conditional approval shall be the designation granted to a program of nursing if one (1) or more of the standards of 201 KAR 20:260 through 20:360 have not been met.
(a) Following the decision of the board to place a program of nursing on conditional status, the program administrator shall be notified of the areas of deficiency and the time frame allowed for corrective action to be implemented.
(b) The program administrator shall, within thirty (30) days of the notice of deficiencies being sent, file a plan to correct each of the deficiencies.
(c) The program administrator may, within thirty (30) days of the notice of the deficiencies, request to appear before the board to contest the board’s determination of deficiencies.
(d) If the board’s determination of deficiencies has not been contested or if the deficiencies being sent are upheld after a request to contest them, the board may conduct periodic evaluations of the program of nursing during the time of correction to determine that deficiencies have been corrected.
(e) If the plan of compliance is not completed satisfactorily within the time frame set by the board and if the program of nursing has not been granted additional time for completion, the approval status of the program of nursing shall be adjusted to probational.
(5) Probational approval shall be the designation granted to a program of nursing if one or more standards have continued to be unmet.
(a) Following the decision of the board to place a program of nursing on probational status, the program administrator shall be notified of the continued areas of deficiency. A new student shall not be admitted until the time the program of nursing comes into compliance. This period of time shall not exceed one academic year.
(b) The program administrator shall, within thirty (30) days of the notice of the deficiencies being sent, file a plan to correct each of the identified deficiencies.
(c) The program administrator may, within thirty (30) days, of the notice of the deficiencies, submit a request to appear before the board to contest the board’s determination of deficiencies.
(d) If the board’s determination of deficiencies has not been contested or if the deficiencies are upheld after a request to contest them, the board may conduct periodic evaluations of the program of nursing during the time of correction to determine that deficiencies have been corrected.
(6) If the program of nursing has not corrected the deficiencies within one (1) academic year of being placed on probational status, a hearing pursuant to KRS Chapter 13B shall be conducted to determine whether to withdraw approval of the program of nursing.
(7) If the board decides to withdraw approval of a program of nursing, upon the effective date of the decision the program of nursing shall be removed from the official approved status listing. A program of nursing whose approval has been withdrawn shall:
(a) Allow a student who is currently enrolled in a nursing class to complete the program of nursing; or
(b) Assist a currently enrolled student to transfer to an approved program of nursing.
(8) A program of nursing whose approval has been withdrawn but continues to operate pursuant to subsection (7)(a) of this section shall be continuously monitored by the board until the program closes.
Section 2. Reports and Examination Pass Rates. (1) A program of nursing that prepares graduates for licensure shall meet all standards of 201 KAR 20:260 through 20:360 in order to retain full approval. Approval status shall be determined annually by the board on the basis of the program’s annual report, NCLEX examination pass rates for first time test takers, and other pertinent data.
(2) A program of nursing shall submit an annual report regarding its compliance with administrative regulations 201 KAR 20:260 through 20:360. A secondary or distance learning site shall be treated independently for purposes of compliance with the regulatory standards.
(3) To verify continued compliance with these administrative regulations, the program administrator shall submit progress reports or periodic supplemental reports, completed questionnaires, surveys, and other documents as requested by the board.
(4) A program of nursing shall maintain at least an eighty-five 85 percent annual pass rate for graduates taking the NCLEX-RN or NCLEX-PN for the first time. Pass rates shall be published on a calendar year basis for those graduates who have tested within twelve (12) months of graduation.
(5) A program of nursing and secondary or distance learning site shall be evaluated individually concerning licensure examination results.
(6) If a program of nursing’s pass rate for first time test takers is less than eighty-five 85 percent for a calendar year, the program administrator shall submit a self study report that evaluates factors that contributed to the graduates' performance on the NCLEX examination and a description of the corrective measures to be implemented.
Section 3. Factors That May Jeopardize Program Approval Status.
Approval status may change for any of the following reasons:
(1) Deficiencies in compliance with 201 KAR 20:260 through 20:360;
(2) Noncompliance with the governing institution or program of nursing’s stated philosophy, mission, program design, objectives/outcomes, or policies;
(3) Continual failure to submit records or reports to the board within the designated time frame;
(4) Failure to provide sufficient clinical learning opportunities for students to achieve stated objectives/outcomes;
(5) Failure to comply with requirements of the board or to respond to recommendations of the board within the specified time;
(6) Failure to maintain the pass rate on the licensure examination for first time test takers as set by Section 2(4) of this administrative regulation;
(7) Withdrawal of accreditation by a national nursing accrediting body recognized by the United States Department of Education.
Section 4. Program Evaluation. (1) The faculty shall engage in a research based planning and evaluation process that incorporates a systematic review of the program of nursing that results in continuing improvement. This process shall result in an evaluation plan that is submitted to the board.
(2) The evaluation plan shall include evidence that data collection is evidence-based, on-going, and reflects the collection, aggregation analysis, and trending of data.
(3) The evaluation plan shall provide evidence that the outcomes of the assessment process are used to improve the quality and strength of the program.
(4) The evaluation plan shall include specific responsibilities for data collection methods, individuals or groups responsible, frequency of data collection, indicators of achievement, findings, and outcomes for evaluating the following aspects of the program:
(a) Organization and administration of the program of nursing;
(c) Resources, facilities, and services;
(d) Teaching and learning methods including distance education;
(e) Faculty performance;
(f) Student achievement of program outcomes;
(g) Graduation rates;
(h) Licensure examination pass rates;
(i) Employment rates of graduates; and
(j) Clinical resources.
(5) If a program of nursing utilizes distance education for didactic instruction, it shall evaluate and assess the educational effectiveness of its distance education program to insure that the distance education program is substantially comparable to a campus based program.
Section 5. Voluntary Closure of a Program. (1) A governing institution seeking to close a program of nursing shall submit written notification to the board at least six (6) months prior to the planned closing date.
(2) A governing institution may choose one (1) of the following procedures for closing a program of nursing:
(a) The governing institution shall continue the program of nursing until the last class enrolled has graduated.
1. The program shall continue to meet the standards for approval until all students enrolled in nursing courses have graduated or transferred.
2. The official closing of the program shall be the date on the degree, certificate, or diploma of the last graduate.
3. The governing institution shall notify the board in writing of the official closing date.
(b) The governing institution shall close the program after the transfer of students to other approved programs.
1. The program shall continue to meet the standards for approval until all students have transferred.
2. The names of students who have transferred to approved programs and the date of the last student transfer shall be submitted to the board by the governing institution.
3. The date of the last student transfer shall be the official closing date of the program.
(3) Custody of records.
(a) The governing institution that continues to operate shall retain responsibility for the records of the students and graduates. The board shall be advised of the arrangement made to safeguard the records.
(b) The governing institution that ceases to exist shall transfer the academic transcript of each student and graduate to the board for safekeeping.
1. The transcript of the student or graduate shall identify the date on which the program closed.
2. The board shall be consulted about the disposition of all other program records.
Section 6. Change in Ownership or Organization of the Governing institution. (1) The governing institution shall notify the board in writing of any intent to transfer administrative authority or ownership. The new administrative authority or owner shall inform the board of its plans for immediate and future operation.
(2) The board shall conduct a site visit to insure adherence by the program of nursing to 201 KAR 20:260 through 20:360.
(3) Following this site visit, approval of the program of nursing shall continue under the new ownership or administrative authority if the approval standards continue to be met. (11 Ky.R. 1709; eff. 6-4-1985; Am. 14 Ky.R. 595; eff. 11-6-1987; 35 Ky.R. 2346; 36 Ky.R. 26; eff. 7-31-2009.)