Complaints and Grounds for Discipline

A. Complaint Policy

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. Jursidiction of the COC

The ANCC COC is an administratively independent certifying component of the American Nurses Credentialing Center, a subsidiary of the American Nurses Association. The COC's review under this policy is limited to certification-related matters. 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).

ANCC may decline to review complaints that, in its discretion, do not fall under Grounds for Action in A.2 of this policy. 

2. Grounds for Action

The grounds for action under this Policy, including grounds for denial, suspension, or revocation of certification, are as follows:

1.  failing to complete or provide evidence of completion of the requirements for initial certification, certification renewal, or reactivation of certification;
2.  failure to maintain the required professional licensure or other authority to practice, including as a result of a conviction of any felony or misdemeanor, or pleading guilty or no-contest to any felony or misdemeanor;
3.  failure to comply with the scope and standards of practice in an area in which certification is held as established by a final decision or order of a state board of nursing;  
4. failure to respond to or comply with ANCC audit inquiries and/or requests;
5. determination that initial certification or certification renewal was improperly granted or that certification was improperly reactivated, including but not limited to instances where it is determined that eligibility, application, or recertification documentation submitted by or on behalf of an applicant or certificant was inaccurate; or any certification irregularity, whether caused by the applicant, ANCC, or a testing vendor;
6. providing false or misleading information; including but not limited to falsification or misstatement of information on any certification-related document;
7. cheating or assisting others to cheat, including but not limited to reproducing, distributing, or discussing by any means examination items/questions or content; acquiring by memorization and recollection from testing or by any other means, and/or knowingly using or acquiring materials containing such content;
8.  causing, creating or participating in an examination irregularity or misconduct; including but not limited to violating test center policies or engaging in any conduct that compromises examination irregularity; 
9. assisting others to wrongfully obtain initial certification or to renew or reactivate certification; 
10.    misrepresentation of ANCC credentials;
11.   conduct unbecoming of the applicable profession that bears directly on certification, the certification process, or practice in the specific field in which certification is held; 
12.  a finding of any of the above by a nursing regulatory body or any other professional certification body. 

3.  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 submitted by email to certcomplaint@ana.org or by mail to ANCC Certification (Attention: Complaints) 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; 
• specify the reason why action should be taken, consistent with the Grounds for Action in this policy;
• include the identify of the complainant; and
• be signed by the complaining party.

The complaint should include all relevant documentation at the time of submission. Inquiries, incomplete submissions, submissions outside of the COC's jurisdiction, submissions other than complaints, and complaints that do not meet the requirements of this section, may be reviewed and handled by ANCC at its discretion. Anonymous complaints may not 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. Upon receipt, ANCC staff will review the complaint to determine whether it  meets the conditions in B.1 Form of Complaints.

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

c. Upon receipt and preliminary review of a complaint, the COC Chair may conclude, in the COC Chair’s or their designee's sole discretion, that the submission: (1) contains unreliable or insufficient information; or (2) is patently frivolous or inconsequential; or is not actionable under this policy. 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.

d. 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. Delegated Staff Action

The CRC may authorize ANCC staff to act on its behalf for administrative cases that do not require disciplinary review by the CRC. All determinations and actions are consistent with this policy. Administrative cases include:
•    resolution of complaint cases originating from failed audits when requirements have been satisfied; or
•    resolution of certification irregularities that do not require adverse action.

ANCC staff may not impose adverse certification action, including denial, suspension, or revocation under this policy. 

4. 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 results 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, renewal, or reactivation.

5. Disposition (or Potential Outcomes)

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.6 Actions Following Disposition, below.

6. Actions Following Disposition

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.

a. 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.

b. 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; 

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

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

e. 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.

7. Notifications and Reporting

a. No Grounds for Action

If the CRC determines that no ground for actions exist, the following written notifications will be made:

• To the Certificant/Applicant/Non-Certificant: A notice of determination will be sent that the CRC determined that no grounds for action exist.
• To the Complainant:  A communication will be sent of the determination that no grounds for action exist.
• Third Parties: 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 grounds for action exist.

b. 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 as outlined in B.6 Actions Following Disposition. The grounds and actions are communicated in writing as follows: 

• 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 in B.6. 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.

c. Notifications to Boards of Nursing and Other Entities of Action Taken

If the CRC takes action against a certificant, applicant, or non-certificant in B.6 Actions Following Dispositions above, a summary of the CRC’s determinations and the disposition may be reported as appropriate to the Board of Nursing, to or at the request of any government entity, and to the certificant’s employer. The certificant, applicant, or non-certificant may share the final notice as their discretion. 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.

8. 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.

9. 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.