1.1.7. Compliance, Concern, and Noncompliance Definitions & Citations

The COA uses the Educational Policy and Accreditation Standards (EPAS) and Interpretation Guide to conduct consistent and complete reviews of programs for candidacy status, initial accreditation, reaffirmation of accreditation, substantive changes, or special compliance reviews. The COA’s reviews, citations, and decision-making are based upon the program implementing, demonstrating, and maintaining compliance with the EPAS or other evaluative criteria. Concern and noncompliance citations are issued when program-submitted content is unclear, incomplete, inadequate, inconsistent, inaccurate, or fail to meet minimum requirements.

Compliance: The program submitted information was clear, complete, and accurate as evaluated by the COA according to the accreditation standards and/or COA’s interpretation.

Concern: The program submitted information was unclear, incomplete, inadequate, inconsistent, or inaccurate as evaluated by the COA according to the accreditation standards and/or COA’s interpretation.

Noncompliance: The program submitted information did not meet the minimum requirements as evaluated by the COA according to the accreditation standards and/or COA’s interpretation.

Understanding Citations
A citation is a concern or noncompliance issue identified by the Commission on Accreditation (COA) based upon the EPAS or other evaluative criteria during an accreditation process.

Citations are documented in a COA-issued letter such as the Letter of Instruction (LOI), deferral letter, decision letter, substantive change letter, or other accreditation letters issued per policies and procedures in the EPAS Handbook.

Citations at the Letter of Instruction (LOI) phase of the reaffirmation process are considered concerns. Citations at the decision phase of the candidacy and reaffirmation processes may be considered concerns or noncompliance issues and will be labeled accordingly within the body of the letter. Citations during a substantive change review and other accreditation processes may be considered concerns or noncompliance issues and will be labeled accordingly within the body of the letter.

Each citation identified in the COA-issued letter will be accompanied by the commission’s findings, a rationale, and instructions for next steps. The reaffirmation LOI is issued directly to the site visitor. Deferrals and substantive change letters are issued directly to the program. All other final COA decisions letters are issued to the program and institutional administrators. The COA employs a fair and impartial peer-review process, ensuring educational programs are provided an opportunity to formally respond to citation(s) identified by the COA or appeal an adverse action.

Occasionally, information provided by the commissioner/site visitor or program may prompt a new citation not identified in a previous accreditation review phase or in between review cycles. In such cases, the following decision trees guide commissioners and/or staff in providing the program an opportunity to respond to the new citation(s).

Candidacy

  • Cite new compliance standard(s) if the...
  • COA reader identified a concern/noncompliance issue in the benchmark documents that was not identified by the commissioner site visitor
  • Program submitted new concern/noncompliance information in their response to the commission visit report
  • Program submitted a new compliance plan that warrants a follow up report (e.g., deferral, progress report, etc.)

In candidacy, draft standards will not be cited; however, staff commissioner visitors, and COA readers may provide consultation and developmental feedback on draft standards.

Reaffirmation

  • COA cite new specific standard(s) if the...
  • Site visitor reported new information based on general questions to which the program did not respond clearly; the new information was evaluated as a concern by the COA
  • Site visitor reported new information based on specific questions to which the program did not respond clearly; the new information was evaluated as a concern by the COA 
  • Program submitted new concern/noncompliance information in their response to general questions
  • Program submitted new concern/noncompliance information in their response specific questions
  • Program submitted a new compliance plan in response to specific questions that warrants a follow up report (e.g., deferral, progress report, etc.)
  • Program submitted new concern/noncompliance information in their response to a COA-requested report (e.g., deferral, progress report, modified site visit, etc.)
Substantive Change
COA cite new standard(s) if the...
  • COA or Accreditation Specialist identified a concern/noncompliance issue in the substantive change proposal that was not previously identified
  • Program submitted a new compliance plan that warrants a follow up (e.g., deferral, virtual visit, etc.)
  • Program submitted new concern/noncompliance information in their response to the deferral or virtual site visit
Special Compliance Review
COA cite new standard(s) if the…
  • Program submitted new concern/noncompliance information in their report
  • COA or Accreditation Specialist identified a concern/noncompliance issue in the report that was not previously identified
  • Program submitted a new compliance plan that warrants a follow up (e.g., deferral, progress report, modified or virtual visit, etc.)
While candidacy, reaffirmation, substantive change, and special compliance review processes are the most common, additional accreditation processes may prompt citations per the policies and procedures in the EPAS Handbook.