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For-profit nursing schools often market their programs to people working in low-level jobs, people looking to improve their life circumstances. Many promise a flexible, expedited education and a supportive environment, in which anyone who works hard can succeed.

But too often the schools fail to deliver on those promises. When that happens, students stand to lose tens of thousands of dollars in federal loans, the chance to sit for their nursing licensure exam, and a career many say they felt called to since childhood.

This is the third story in our series on for-profit nursing programs. As part of our investigation, MedPage Today spoke with more than a dozen current and former nursing students, as well as academics, nursing professors, and regulators.

In December 2019, Kim Bailey, a single mother working at an animal shelter, came across an ad for HCI College's accelerated associate degree in nursing program on Facebook.

Bailey, a veteran, was fascinated by wounds and wanted to become a wound care nurse.

She had completed her prerequisites for nursing at Palm Beach State College but applied there and was rejected from its core nursing program twice. Wait lists are not unusual at public and non-profit nursing schools, but HCI's accelerated program offered immediate entry, accepted most of Bailey's previous credits, and would take only 18 months to complete.

HCI College (originally Health Career Institute) was founded in 1993 as a non-profit institution to train emergency medical service personnel, according to its . It was reincorporated as a for-profit institution in 2012, and in 2013. That same year, the Florida Board of Nursing (BON) granted approval for HCI to open a nursing program.

On its , the college currently advertises access to day and evening classes, financial aid for those who qualify, and 24/7 access to live tutors. Importantly, for graduates, the program also provides eligibility to take the National Council Licensure Exam (NCLEX), which is required to become a registered nurse.

Bailey passed the entrance exam on her first try. After using her remaining G.I. Bill benefits and taking out a private loan, she enrolled and began classes in HCI's core program in August of 2020.

Rebecca Freeman, a former HCI student and contract support specialist, looking to make a "nice fast career change" was also drawn to the college for its convenience.

Because she had recently earned a medical assistant certificate, she recalls being told she could finish the nursing program in just 1 year.

"There was no waiting list ... You just had to take an entrance exam," Freeman said during a phone interview with her lawyer's public relations representative present.

During her tour of the college, in September 2020, admissions officer Krystal Zimbaldi told Freeman that the school's pass rates on the NCLEX were between 80% and 100%, and that it was accredited by the Accrediting Commission of Career Schools and Colleges (ACCSC) -- a national accrediting agency.

After a phone call to her husband, Freeman enrolled that day.

Both Bailey and Freeman now say HCI crushed their dreams of a nursing career by not delivering what it promised. Freeman, Brittany Roberson, Bianca Viñas, and Tiffany King -- all former HCI students -- sued the school on Dec. 2, 2022. Tresha Thompson, another former HCI student, later joined them.

Their charged HCI College, Florian Education Investors, and Steven Hart (chairman of HCI and CEO of Florian), with having "systematically imposed unfair and arbitrary barriers" on students to prevent them from graduating and taking the NCLEX.

In the meantime, Bailey "maxed out" her G.I. Bill credits; she still owes more than $6,000 in private loans and believes she owes $3,000 to the Department of Veterans Affairs for a housing stipend.

Bailey has not attempted to sue the school or requested a refund. She set aside her dream of becoming a wound care nurse and continues to work at an animal shelter.

Freeman said she has about $12,000 in out-of-pocket expenses and owes about $20,000 in federal loan debt. She is currently repeating her entire degree from scratch at Indian River State College.

Both their stories are emblematic of the problems critics believe underlie for-profit nursing programs.

Promises vs Reality

During her HCI orientation, something felt amiss, Freeman said. She expected to hear the "game plan" in terms of course expectations, and how to use online assignment tools, but "we weren't really oriented to anything."

Bailey said that despite the promise of tutors and individualized support, when she started to struggle with her courses, no one was available to help. The one instructor who did offer support was only ever free during Bailey's work hours. Bailey recalls that that same professor later refused to give her an extension on a key assignment when she was in the hospital with COVID overnight.

In her first semester, Bailey had been impressed with the simulated clinicals, and had drawn real-looking blood from a fake arm. But after a few weeks of simulated clinicals in her second semester, she arrived to find the instructor was on leave. Yet for nearly a month, students were still required to show up one full day a week for mandatory study hall, she said.

"I was going crazy," said Bailey. "We're paying so much money ... and there's no instructor!"

Tuition was approximately $10,000 per semester, and the course was expected to take five semesters.

In early 2021, Bailey dropped out of the program.

Freeman, however, said she was lucky to land a clinical rotation at the Weston, Florida branch of the Cleveland Clinic, but that when the hospital terminated its relationship with HCI in the summer of 2021. (A spokesperson for the Cleveland Clinic declined to comment on any relationship with HCI due to pending litigation.)

Also in the summer of 2021, HCI implemented what was known as "," Freeman said. On every proctored exam, students had to score 50% or more questions right in each category in addition to scoring 80% or higher overall on the exam, she said. The catch: some categories had only two or three questions. So a student could get one or two questions wrong and fail the whole exam, she said. And because of the new rules, many of her fellow students were "sliced out" of the program.

By December 2021, Freeman had survived the 50% rule, completed the required credits, scored 80% or higher in the core nursing curriculum, 70% or higher in the general education courses, and passed the Assessment Technologies Institute predictor exam. In other words, she met all of . Then, during the "Capstone" portion of her final semester, the students were required to take an exit exam. They were told neither the type of exam nor the benchmark for passing. The exam was given at 7 p.m., after a full day of class, Freeman said.

A few hours later, an email from the assistant dean of nursing popped up in her inbox, telling her she had failed the test and needed to repeat the semester. Freeman and a few other students who refused to repeat the course attempted to appeal the decision. According to , she should have been allowed to retake the exam, Freeman said.

They met with administrators, but "it was the same stone wall wherever you went," Freeman said. "'Oh, we're sorry about your luck.'"

Institutions submit names to the BON confirming individual student's graduation and their eligibility to take the licensure exam -- in Freeman's case, the NCLEX-RN. HCI gave no such permission to Freeman. It did eventually allow her to take the NCLEX-PN and become a licensed practical nurse.

Pedro De Guzman, president and CEO of HCI College, disputes the claims made by former students like Freeman and Bailey.

Regarding the surprise nature of the exit exam format, that was a step the school took to "protect the integrity of our program," and prevent cheating, he said.

As for the clinical rotations, De Guzman said the only time HCI had difficulty placing students was during the pandemic, and he had no knowledge of any rotations being turned into study halls.

Asked about the 50% rule, he wrote in a follow-up email that "[a]ny concept taught in the semester or program may appear on any exam, regardless of the course ... The students get four chances by the end of the semester to demonstrate mastery (score 50% or better) on the concepts."

Finally, with regard to complaints about a lack of support, he noted that the school offers online tutoring "24 hours a day, 7 days a week."

"Sometimes the students aren't happy with the toughness of the program, but we don't make apologies for that," De Guzman said. "Because if ... we made it easy as they got through and nobody could pass [the NCLEX], then we'd have a different problem."

Standards Plummet, Schools Multiply

The problems Bailey, Freeman, and other students encountered may have resulted in part from policy actions taken more than a decade earlier.

About 5 years ago in Florida, "you couldn't throw a stone without hitting a nursing school, because the standards, the regulations, were so poor that nursing schools were popping up everywhere," Maria Flores-Harris, DNP, RN, president of Academic Partners Consulting, who worked in the state up until 2022, told MedPage Today.

The story behind the explosion of nursing schools in Florida, many of them for-profit, dates back to 2009, when the Florida legislature to the state's Nurse Practice Act that made it easier for new nursing programs to open.

Previously, the law directed the Florida BON to "" around, for example, the minimum faculty qualifications or clinical training required for a program to receive initial approval from the board. It also allowed the BON to conduct site visits to programs to assess quality firsthand.

Under the new law, although the state's BON still determined which schools to open, which to monitor, and which to close, the Florida BON could no longer set the criteria for making such decisions.

"It took away all the teeth of the Board of Nursing," said Patricia "Polly" Pittman, PhD, professor of health policy and management at the Milken Institute School of Public Health at George Washington University, whose on nursing board exams.

The board approved 231 new nursing programs from 2009 to 2013, nearly doubling their numbers, according to a 2014 report from the (OPPAGA).

The number of nursing program graduates also shot up more than 25% -- from nearly 12,000 in 2008-2009 to more than 15,000 in 2012-2013, the report noted. But that was the point: lawmakers wanted to mitigate the nursing shortage, as well as quiet complaints of bias from for-profit programs.

But there was a problem -- NCLEX pass rates fell as more and more nursing schools opened, recalled Willa Fuller, BSN, RN, executive director of the Florida Nurses Association. (To become a registered nurse in the U.S. or Canada, a nursing school graduate must first pass the NCLEX exam.)

In 2015, approximately 42% of all nursing programs in Florida had pass rates below required state standards, according to a . And the majority of those programs opened after 2009.

Perhaps more worrisome, according to Jessie Colin, PhD, RN, who served on the Florida BON from 2005 to 2015, was that the BON appeared to Colin to be unable to correct the problem.

It would close one failing program, only to have it reapply under another name or address. And the BON had no avenue under the legislation to deny the application if the program met the legislature's criteria, Colin said.

As a board member, it felt to her like "our hands were tied behind our backs."

At the BON's urging, the legislature in 2017 , requiring that a terminated program wait a minimum of 3 years to again seek program approval "under its original name or a new program name" -- but other problems emerged.

For example, having so many new nursing programs put pressure on clinical sites to serve more and more nursing students.

"There's only so many students you can burden nurses with when they're trying to work, and still be safe," Fuller said.

Not long ago, Fuller said, she received a call from a nurse concerned about a recent graduate who had "never touched a patient" and "never been in a hospital." Fuller stated that she and her colleagues also had reports of non-nurses, emergency medical technicians, and school administrators teaching nursing classes.

"It would be like me going and teaching a course to air traffic controllers," she said.

Florida's first-time NCLEX pass rate for 2022 was 63.9%, earning it the last spot in the nation's rankings for the sixth year in a row.

Asked what might reverse this decline, Fuller said she hopes lawmakers will reconsider the changes lawmakers made to the BON more than a decade ago, she said.

When the legislature threw open the doors to nursing program approval in 2009, Fuller believes the goal was to churn out more students to respond to an anticipated nursing shortage.

"Imagine if they said that about doctors," Fuller said. "Let's just open a medical school on every corner ... People would find that alarming."

But advancing the kinds of reforms many nurse leaders think are needed will require a major shift in the image the public, and particularly lawmakers, have of nurses and nursing school, she said.

Nursing school is about more than learning to do tasks and take tests; it's about role-modeling and instilling a code of ethics. Nurses are also often the first to notice serious complications and to intervene -- by calling a physician or springing to action themselves. That individual has to have the knowledge and the clinical judgment to know "what to do and when to do it," Fuller said.

This isn't 19th-century nursing, Fuller said. "We're not roaming the halls with a lamp just making people feel good."

HCI College: Missing Clinicals, High-Stakes Exams

By if a program's pass rates by first-time U.S. educated test takers on the NCLEX fall more than 10 percentage points below the national average for 2 consecutive years, the program is placed on probation. Once on probation, a program has 1 year to meet minimum standards or be "terminated," although schools that show progress may get an extension of 1 more year.

In their lawsuit, Freeman and the other plaintiffs allege that HCI allowed only those students with the greatest chance of passing the NCLEX to graduate in order to "artificially inflate" its NCLEX pass rates and prevent the program from being shut down.

As of February 2023, only nine graduates out of the 100 students who were expected to complete the program in December 2021 had taken the NCLEX, according to the lawsuit.

According to Freeman and the other plaintiffs, that wasn't the college's only failing. Students feel that HCI allegedly gamed the BON's rules in a different manner as well.

HCI has two Florida campuses: one in West Palm Beach and one in Fort Lauderdale. Curiously, in May 2018, HCI applied to open a "new" program at its West Palm Beach campus, listing the same instructors, curriculum, facilities, course catalog, and nursing director as an existing program that had been granted BON-approval 5 years earlier. According to the students' complaint, HCI did not acknowledge its existing program -- which had been placed on probation in 2018 -- in its application for the new one.

Adding one more wrinkle to the story, according to , in March 2018 -- 2 months prior to applying for approval of its new program -- HCI brought an administrative challenge to the BON, arguing that the board had "improperly calculated" its pass rates. Had the board used HCI's "preferred calculation methodology," it would still have been placed on probation, the student's complaint asserted.

In October 2018, perhaps unknowingly, the BON approved HCI's "new" program at the West Palm Beach campus, despite a that requires the board to deny approval of any program if the applicant has an existing program that is already on probation. Less than a year later, on Aug. 7, 2019, according to , the BON forced the original program to close for failing to obtain accreditation from a specialized nurse accrediting agency by the deadline -- essentially a 5-year window -- established under . Why the BON approved HCI's new program despite its old program having been on probation, and arguably on the road to closure, is unclear.

Eileen Connor, JD, president and director of the Project on Predatory Student Lending, who represents the students suing HCI, said the board appears to have the "power and responsibility" to monitor programs but lacks the resources to do so effectively.

Importantly, once HCI's "new" program was approved, its West Palm Beach campus received a new NCLEX code. This bought the college time -- 5 additional years -- to earn programmatic accreditation, the complaint noted.

Then, in the spring of 2019, HCI College -- then known as the Health Career Institute -- requested a name change. The Florida Commission for Independent Education approved the request.

In September 2019, HCI began to enroll students in its "new" program under its new name: HCI College. Each newly enrolled student at HCI College was given a state-mandated disclosure form comparing HCI's pass rates to the national pass rate for the NCLEX in 2018, which was 85.11%. That same year, there were zero students from HCI who took the licensure exam, the form noted. HCI also indicated that in 2018, the program was "not on probation."

With its new NCLEX code, Connor told MedPage Today, HCI was given "a clean slate when they actually had terrible passage rates, terrible completion rates, and they didn't have to tell anyone that."

De Guzman, HCI's president, disagrees with Connor's assertions. De Guzman explained that when a program is given a new NCLEX code, "you only can disclose what you have as a history of that number"; however, pass rates for the original program under the prior NCLEX code "are still a matter of record," he said.

"We did disclose our entire history to the students when they came in [and] enrolled," he told MedPage Today in a phone interview during which a press representative was present.

(Zimbaldi, HCI's admissions officer at that time, did not respond to interview requests from MedPage Today.)

For 2018, the "old NCLEX" pass rate for the West Palm Beach campus was 54.93%, De Guzman wrote in a follow-up email. The 2018 NCLEX pass rate for Florida was 67.52%, he noted. Even while on probation, HCI's pass rates "weren't embarrassingly low compared to a lot of other schools in the state," De Guzman said over the phone.

"Nursing schools are tough, and we're proud of what we've been able to achieve this past year with an 89% pass rate," which "puts us in the top 10% in the state" across all program types -- whether for-profit, non-profit, or public, he told MedPage Today.

The BON has not responded to multiple requests from MedPage Today to discuss its oversight of nursing programs or its interactions with HCI.

Can Florida Ever Recover?

The story of HCI represents just one for-profit nursing program. However, for-profit institutions in Florida have had their share of difficulties. For one thing, more than half of the nursing schools alleged to be involved in the fake diploma scheme dubbed Operation Nightingale are for-profit institutions.

In 2022, between for-profit RN programs and non-profit RN programs in the state was more than 25 percentage points -- 52.71% versus 78.94% -- according to a report published in January.

While these are "very low" numbers, said Rayna Letourneau, PhD, RN, executive director of the Center for Nursing, not every for-profit institution is low-performing, she stressed.

In northwest Florida, for example, for-profit programs had first-time pass rates significantly higher than those in the south and south-east parts of the state. Notably, .

But NCLEX pass rates tell only one part of the story, said Connor, of the Project on Predatory Student Lending.

To focus solely on test-takers is to look at the wrong denominator, Connor told MedPage Today. Pass rates exclude students who don't graduate or take the NCLEX, but are still left with debt, she said. Connor said regulators should also track and make use of overall completion and dropout rates when evaluating a program's performance.

Specialized nursing accreditation is an indicator of a program's overall performance that involves a more rigorous review than board approval or even some other types of accreditation. Nursing accrediting agencies, of which there are three, share the goal of establishing consistent standards across all programs.

There is no "blanket" rule that all for-profit schools are underperforming schools, Fuller said. Longstanding for-profit institutions perform well, particularly those with specialized nursing accreditation, said Fuller, because they "follow those standards that we followed in the past."

It appears it was the lack of specialized accreditation that forced HCI's original nursing program to close in 2019. To date, neither HCI campus has received specialized nursing accreditation.

Data from 2020 through 2022 show pass rates for these accredited programs that are consistently higher than those without this distinction, Letourneau said.

However, as our MedPage Today investigation has shown, even accredited programs sometimes fail.

Connor supports the idea of requiring programmatic accreditation but said there should be a "stricter timeline for attaining it."

Some schools are unlikely to obtain accreditation but apply anyway, then slow-walk the actual assessment process. In the interim, they soak up large amounts of students' tuition and federal loan dollars. "And it's that time that is really hurting the [student] population that's getting lured into these schools," she said.

For Fuller, rebuilding the profession means rethinking past mistakes. "We would like to see the law just put back in place the way it was," she said, referring to the in place prior to 2009, adding that she would also like to see an incorporation of requirements for accreditation.

Letourneau agreed that something needs to change. "We need more qualified nurses. That doesn't necessarily mean that we need more nursing education programs," she said.

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