201 KAR 20:360. Continuing approval and periodic evaluation of prelicensure registered nursing and licensed practical nursing 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 regulation 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. Program of Nursing Accredited by a National Nursing Accrediting Body. (1)(a) A prelicensure registered nursing or licensed practical nursing program that is accredited by a national nursing accrediting body recognized by the United States Department of Education shall be deemed to be in compliance with the standards of 201 KAR 20:260 through 201 KAR 20:360 and shall not have to demonstrate compliance every eight (8) years as required by Section 2 of this administrative regulation. The accredited program shall comply with Sections 3 through 10 of this administrative regulation.
(b) The board shall retain jurisdiction over accredited programs and may conduct site visits or other investigations into any allegation that may constitute a violation of 201 KAR 20:260 through 201 KAR 20:360. The board may also conduct site visits in accordance with Section 5 of this administrative regulation.
(2) A prelicensure program of nursing that is accredited by a national nursing accrediting body recognized by the United States Department of Education shall submit all correspondence and reports to and from the accrediting body to the board within thirty (30) days of submission or receipt.
Section 2. Programs of Nursing Not Accredited by a National Nursing Accrediting Body. (1) A prelicensure registered nursing or licensed practical nursing program that is not accredited by a national nursing accrediting body recognized by the United States Department of Education shall be required to demonstrate compliance with 201 KAR 20:260 through 201 KAR 20:360 at least every eight (8) years for continued approval.
(2)(a) A site visit shall be conducted at least every eight (8) years.
(b) A specific list of information required for review shall be sent by the board to the program of nursing prior to the site visit.
(3) Prior to the site visit, the program of nursing shall submit:
(a) A self-evaluation report that provides evidence of compliance with 201 KAR 20:260 through 201 KAR 20:360; and
(b) Other related information as requested by the board.
Section 3. Reports and Evaluation. (1) A program of nursing shall submit the Annual Report of the Program of Nursing to the board regarding its compliance with 201 KAR 20:260 through 201 KAR 20:360.
(2) To verify continued compliance with 201 KAR 20:260 through 201 KAR 20:360, the program of nursing shall submit progress reports or periodic supplemental reports, completed questionnaires, surveys, and other related documents as requested by the board.
(3) Pursuant to 201 KAR 20:260, Section 2(7)(a), the faculty shall establish an evaluation plan and shall engage in an evidence 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 report that is submitted to the board. Revisions to the evaluation plan or report shall be submitted with the annual report.
(4) The evaluation plan shall include evidence that data collection is evidence-based, on-going, and reflects the collection, aggregate analysis, and trending of data.
(5) 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 evaluation;
(f) Student achievement of program outcomes;
(g) Graduation rates;
(h) Licensure examination pass rates;
(i) Employment rates of graduates; and
(j) Clinical resources, including laboratory and simulation.
(6) 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 ensure that the distance education program is substantially comparable to a campus based program.
(7) The evaluation report shall provide evidence that the outcomes of the evaluation process are used to improve the quality and strength of the program.
Section 4. Calculation of Pass Rate. (1) The board shall calculate the pass rate for a program of nursing on an annual basis from January 1 to December 31 for all first time takers of the NCLEX.
(2) Individuals included in the annual calculation shall have tested within six (6) months of the program completion date as reported on the Certified List of Kentucky Program of Nursing Graduates or the Certified List of Out-of-state Program of Nursing Graduates incorporated by reference in 201 KAR 20:070.
Section 5. Site Visits. (1) The board may conduct site visits at any time.
(2) The following situations may be cause for a site visit to determine if the standards of 201 KAR 20:260 through 201 KAR 20:360 are being met:
(a) Denial, withdrawal, or change of status by a national nursing accrediting agency;
(b) Providing false or misleading information to students or the public concerning the program;
(c) A written complaint received from faculty, students, or the general public relating to a violation of 201 KAR 20:260 through 201 KAR 20:360;
(d) A change in physical facilities;
(e) Information received by the board that may indicate a violation of 201 KAR 20:260 through 201 KAR 20:360;
(f) A change in any of these benchmarks:
1. A pass rate as calculated by Section 4 of this administrative regulation that:
a. Is less than an average of eighty-five (85) percent for three (3) consecutive years; or
b. Varies above and below eighty-five (85) percent from year to year over the previous five (5) years;
2. A faculty turnover rate greater than thirty (30) percent for two (2) consecutive years;
3. A program administrator turnover rate of more than three (3) individuals in five (5) years;
4. A graduation rate of less than sixty (60) percent of the admitted cohort within the maximum time frame allowed for completion. The maximum time frame shall be determined by multiplying the standard program length for normally progressing students by 1.5;
5. Twenty-five (25) percent or more of the total number of nursing faculty who file grievances or appeals that are substantiated; or
6. Substantiated student grievances and appeals of more than ten (10) percent of the nursing student population each year; or
(g) Failure to submit reports as required by 201 KAR 20:260 through 201 KAR 20:360.
Section 6. Action Following Site Visit. (1)(a) Following a site visit and prior to board consideration, a draft of the site visit report shall be made available to the program administrator for review and correction of factual data.
(b) The program administrator shall be available during the discussion of the report at the board committee to provide clarification.
(c) If the site visit results in a finding of non-compliance with 201 KAR 20:260 through 201 KAR 20:360 by the program of nursing, a letter shall be sent to the program administrator regarding any requirements to be met.
(d) The board shall notify the program of nursing of the time frame within which it shall meet the requirements. The board shall verify that the requirements have been met.
(2)(a) If the program of nursing is unable to meet the requirements in the time set by the board, it may request additional time. The board, in its discretion, may grant or deny this request based on the rationale for the request.
(b) If the board denies the request for additional time, it shall begin the process established in Section 7 of this administrative regulation.
Section 7. Withdrawal of Approval. (1) If, in the opinion of the board, the standards established by 201 KAR 20:260 through 201 KAR 20:360 are not being met, the board shall send notice to the program administrator of the affected program of nursing of its intent to withdraw approval. The notice shall be sent return receipt requested.
(2) When making this determination, the board shall consider the following factors:
(a) The number and severity of the deficiencies;
(b) The length of time in which the deficiencies have existed; and
(c) Any exigent circumstances.
(3) Within thirty (30) days of receipt of the notice, the program administrator of the affected program may request an administrative hearing pursuant to KRS Chapter 13B. If an administrative hearing is not requested, program approval shall be withdrawn and the program shall be closed. A closed program shall comply with subsection (5) of this section.
(4)(a) If a program of nursing requests an administrative hearing, that hearing shall be held within sixty (60) days of the request.
(b) The hearing shall be held before a hearing officer or before the full board.
(5)(a) A program of nursing whose approval has been withdrawn by the board shall be removed from the official approved status listing upon the effective date of the decision. Students currently enrolled in the last semester or quarter of the program may complete the program. If the student graduates, he or she may apply for licensure and make take the licensure examination. Any other student shall not be allowed to apply for licensure or take the licensure examination, unless the student graduates from another approved program of nursing.
(b) The program of nursing that has been closed shall assist a currently enrolled student to transfer to an approved program of nursing.
Section 8. 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 as established in paragraph (a) or (b) of this subsection.
(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 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 following the transfer of students to other approved programs.
1. The program shall continue to meet the standards 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 9. 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 ensure adherence by the program of nursing to 201 KAR 20:260 through 201 KAR 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.
Section 10. Incorporation by Reference. (1) "Annual Report of the Program of Nursing", 12/15, Kentucky Board of Nursing, is incorporated by reference.
(2) This material may be inspected, copied, or obtained, subject to applicable copyright law, at the Kentucky Board of Nursing, 312 Whittington Parkway, Suite 300, Louisville, Kentucky 40222, Monday through Friday, 8 a.m. to 4:30 p.m. (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; 40 Ky.R. 2346; 41 Ky.R. 24; eff. 8-1-2014; 42 Ky.R. 2430, 2587, 2726; eff. 6-3-2016.)