Complaints Against a Certificant, Applicant or Non-Certificant Policy & Procedure

The Commission on Board Certification (COC) of the American Nurses Credentialing Center (ANCC) will receive and investigate reports of certification misconduct, testing irregularities or scoring anomalies (complaints) against ANCC certified individuals (certificants) and applicants for ANCC certification (applicants) for misconduct related to certification or eligibility for certification. The COC will also receive and investigate reports regarding non-certificants, individuals who are neither applicants nor certificants, who are alleged to have held themselves out in some way as being ANCC certified or have participated in certification misconduct.

1. Background

a. The ANCC was established as a certification body for the evaluation of individuals who wish to enter, continue, and/or advance in the nursing profession through the certification process. The ANCC COC is an administratively independent certifying component of the American Nurses Credentialing Center, a subsidiary of the American Nurses Association.

b. Certificants are those who have successfully completed the required certification process, which includes meeting all educational requirements, verifying professional knowledge, passing a certification examination, and demonstrating experience in the profession. Successful candidates are awarded ANCC certification and may hold themselves out to the public as ANCC certified.

c. In order to maintain and enhance the credibility of the ANCC Certification Program, the COC adopts these administrative procedures for receiving, investigating and resolving complaints concerning certification (certification misconduct).

d. The COC may take action against certificants, applicants for certification, and non-certificants who are found to have engaged in certification misconduct or found to have been granted the certification incorrectly (certification irregularity).

2. Grounds for Action

The grounds for action under this Policy are:

A. Conviction of any felony or misdemeanor, or pleading guilty or no-contest to any felony or misdemeanor, which results in loss of licensure;

B. Any cause for denial, suspension or revocation of certification identified in the COC Policy II-05 Causes for Denial, Suspension, and Revocation of Certification; 

C. A finding of any of the above by a nursing regulatory body or any other professional certification body; and

D. Any certification irregularity, even if the irregularity was caused by ANCC or a testing vendor.

3.  Scope of Policy

The administrative procedures set forth in this policy apply to all complaints received about a certificant, applicant and non-certificant that satisfy the requirements set forth in Section B.1. of this policy.

4.  No Relief for Complainant

Actions taken in furtherance of this policy do not constitute enforcement of the law, although referral to appropriate federal, state, or local government agencies may be made about the conduct of the certificant, applicant or non-certificant, in appropriate situations. Complainants are not entitled to any relief or damages by virtue of this process, although they may receive notice of the outcome.

B. Complaint Procedures

1. Form of Complaints

Complaints may be submitted by any individual or entity. Complaints must be in writing and directed to the Assistant Director, Certification, Accreditation and Governance, by email to certcomplaints@ana.org or mail to ANCC Certification at 8403 Colesville Road,  Suite 500, Silver Spring, MD  20910. The complaint must include the name of the certificant, applicant, or non-certificant for which the complaint is being filed;  must specify the reason why the complainant believes that action should be taken; include the identify of the complainant; and be signed by the complaining party. Inquiries or submissions other than complaints, and complaints that do not meet the requirements of this paragraph, may be reviewed and handled by ANCC at its discretion. Anonymous complaints may note be investigated.

In accordance with the Health Insurance Portability and Accountability Act (HIPAA) and other laws and regulations, protected health information, inclusive of personal medical records, should not be included in complaints or responses.  Submissions including such information will not be accepted.

2. Intake and Preliminary Review

a. Within 10 business days of receipt of a complaint, ANCC staff shall forward the complaint to the Chair of the Commission on Board Certification (COC Chair) for preliminary review.

b. Upon receipt and preliminary review of a complaint, the COC Chair may conclude, in the COC Chair’s sole discretion, that the submission: (1) contains unreliable or insufficient information; or (2) is patently frivolous or inconsequential. In such cases, the Chair may determine that the submission does not constitute a valid and actionable complaint that would justify a full investigation and a determination of appropriate action, and may dismiss the complaint without investigation. If a complaint is dismissed without investigation, the complainant shall be notified.

c. If the COC Chair determines that a complaint warrants investigation, the COC Chair will:
  i. ensure that written notice of the complaint and investigation is given to the individual whose conduct or certification is in question;
  ii. provide for a full investigation, including the gathering of relevant documentation; and
  iii. assign to a standing Complaint Review Committee (CRC) assembled by the COC Chair of three individuals, who may or may not be   members of the COC but who may not be members of the COC appeals committee, to investigate and make an appropriate determination of whether certification misconduct warranting action occurred.

3. Investigation

a. For each complaint warranting investigation, the COC hereby authorizes an investigation into its specific facts or circumstances to whatever extent is deemed necessary, within its sole discretion, in order to clarify, expand, substantiate or refute the allegations. The CRC may seek staff assistance in conducting the investigation.

b. The individual whose conduct or certification is in question shall be given a written notice of the complaint, which notifies them of the fact that the complaint is being reviewed by ANCC and that they have an opportunity to respond in writing to the complaint and to provide relevant documentary evidence for the CRC’s review and consideration.

c. Responses and all supporting documents are due within 20 business days of receipt of the correspondence providing notice of the complaint. However, the CRC, at its sole discretion, may grant extensions of time for providing responses or additional information. The CRC may also shorten the time period for response if a complaint involves allegations that pose an immediate and imminent threat to public safety. The CRC may also independently elect to seek additional information after a complaint response is received and shall establish timelines for any such request.

d. As part of its investigation, the CRC, or ANCC staff acting on its behalf, may contact any individual who may have knowledge of the facts and circumstances surrounding the complaint or information that may assist the CRC in resolving the complaint.

e. All investigations and deliberations of the CRC and ANCC are conducted in confidence, to the extent possible. All investigations and deliberations of the CRC and ANCC are conducted objectively, without prejudgment. An investigation may be directed toward any aspect of a complaint which is relevant or potentially relevant. Formal hearings are not held, and the parties are not expected to be represented by counsel, although the CRC and ANCC may consult their own counsel.

f. ANCC may hold examination scores or delay conferral of initial certification or delay renewal or a reactivation of a certification if an applicant has an open complaint pending prior to the official grant of certification.

4. Disposition (or Potential Outcomes)

a. Determinations

Upon completion of an investigation, the CRC makes the following determinations:

• Whether grounds for further action by the CRC exist; and
• What further action is appropriate, as set forth in Section B.5. Actions Following Dispositions, below.

 

b. Notice of Determination: No Grounds for Action

• To the Certificant/Applicant/Non-Certificant:  Notified, in writing, that the CRC determined that no grounds for action exist.
• To the Complainant:  Notified, in writing, of the determination that no grounds for action exist.
• At the Certificant’s/Applicant’s/Non-Certificant’s Request:  At the request of the individual whose conduct or certification was in question, written notice will be provided to that individual’s employer(s), government agencies or other third parties that the CRC determined that no groujnds for action exist.

 

c. Notice of Determination: Existence of Grounds for Action
If the CRC makes a determination that grounds for action exist, then the CRC shall determine the actions to be taken including: written assurance, other conditions, and/or deny, suspend, or revoke certification.

• To the Certificant/Applicant/Non-Certificant:  A notice of action will be sent in writing that the CRC determined grounds for action exist and of the actions taken as outlined below under B.5. Actions Following Disposition. 
• To the Complainant:  Notified, in writing, of the disposition of the complaint.
• Notice to COC:  All action(s) taken by the CRC against certificants/applicants/non-certificants under this policy shall be reported to the COC.

 

5. Actions Following Disposition

a. Actions
The CRC may take any of the following actions against certificants, applicants and non-certificants whom the CRC has determined to have engaged in certification misconduct or granted the certification incorrectly. The action taken must reasonably relate to the nature and severity of the violation.

  i. Written assurance - If, in the CRC’s discretion, the circumstances demonstrate that denial, suspension,or revocation of certification is not warranted but a matter exists that requires correction, the CRC may give the individual whose conduct was in question the opportunity to submit a written assurance that the correction will be made. The decision of the CRC to make and accept such written assurance, with or without any conditions that the CRC may impose, is within the CRC’s discretionary powers. If such an offer is extended, the individual whose conduct was in question must submit the required written assurance within thirty days (30) calendar days of receipt of the offer and satisfy any and all conditions of the offer, and the assurance must be submitted in terms that are acceptable to the ANCC. Written assurance is only available to individuals who have not been sanctioned previously by ANCC.

The CRC may also impose written assurance in addition to denial, suspension or revocation as a condition precedent to the acceptance of future applications for certification or renewal.

  ii. Other Conditions - including completion of continuing education or other conditions deemed necessary in light of grounds and that reasonably related to the nature and severity of the violation; 

  iii. Denial of eligibility for any or all ANCC certifications;

  iv. Suspension of certification(s) or assessment-based certificate for a designated period determined by the CRC, in its discretion; and

  v. Revocation of any or all ANCC certifications. Individuals who are disciplined by revocation may be ineligible for future certification or recertification. In the event of revocation, the individual must cease from holding themselves out, in any way, as certified by ANCC.

b. Reporting
For each of these sanctions, a summary of the CRC’s determinations and the disposition will be reported as appropriate to the Board of Nursing, to or at the request of any government entity, and to the certificant’s employer. Unless the CRC has determined that there is an immediate safety threat, this summary shall not be sent to the Board of Nursing, any government entity or to the certificant’s employer until either 1) the time for filing a notice of appeal has elapsed (without the certificant or applicant providing timely notice) or, 2) where the certificant or applicant has provided timely notice, after the appeal has been heard and affirmed by the Appeal Committee.

6. Right to Appeal

An individual against whom action has been taken under this policy may appeal in accordance with the COC Appeal Policy and Procedures applicable at the time the Notice of Appeal is filed. An individual wishing to appeal an adverse decision (Appellant) of the CRC must submit a complete Notice of Appeal to the staff identified in the CRC notice of action letter, within twenty (20) business days following the electronic mail sent date. Except where the Appeal Committee has granted in writing a request for an extension of time made prior to the end of the response period, an individual who fails to provide notice within the time and manner specified in the Appeal policy, will lose their right to appeal and the adverse decision will be final.

7. Voluntary Surrender of Certification

A certificant who is the subject of a complaint may voluntarily surrender their ANCC certification(s) at any time when a complaint is pending under this Policy.  If certification is voluntarily surrendered, the complaint is dismissed without any further action by the CRC, ANCC, or the Appeal Committee. A certificant who voluntarily surrenders certification under this policy may be permitted to reapply for future certification or recertification at the CRC’s discretion. Voluntary surrender of certification, the date of surrender, and the fact and general nature of the complaint that was pending at the time of surrender will be reported, as appropriate, to the Board of Nursing, to or at the request of any government entity, and to the certificant’s employer.