Pending CMP Grant Funded Project for Indiana Nursing Facilities


Register to participate (pending grant funding approval) by August 15!

The “Empowering Excellence” grant project aims to develop and nurture nurse leaders within long-term care (LTC) facilities through enhancement of facility-wide systems for nurse leadership skill development, career advancement pathways and nursing staff retention. The project’s objective is to improve quality of care and staff engagement through a LTC nurse leadership development program that fosters a culture of continuous improvement and provides facility program certification for successful project completion. By participating, facilities will empower nursing staff through structured career growth and leadership engagement opportunities, promoting better resident outcomes, increased staff satisfaction, and a more resilient healthcare environment for LTC residents. Training, resources, and support are provided at no charge to participating facilities. The project is pending approval by the Indiana Department of Health.

Practical Solutions to Address the Shortage of Nurse Leaders, Lack of Leadership Development Programs, and Retention Issues

  • Nurse Leadership Skills Development through weekly nurse leader engagement opportunities which include education, mentorship, and cohort groups.
  • Facility Career Pathway Implementation to provide structure and motivation for the advancement of RN, LPN and CNA nurse leaders.
  • Facility Specific Project Completion that includes components of assessing facility opportunities for improvement and developing a project that fills identified gap in staff leadership development, staff engagement, or other area that contributes to staff satisfaction and long-term retention.

Participation Requirements

  • Facilities must commit to participating in the project for its entire duration and allocate time for participating nursing staff to attend every other week training modules and cohort meetings in the opposite week (1.25 hours per week commitment).
  • The project can be completed in as little as 6 months, but participants may opt to complete the project over up to 24 months.
  • Facilities must register by submitting the Expression of Interest Form by 8/15/24 in order to participate in the project if and when funding is approved.


  • Enhanced staff competency, engagement and confidence.
  • Improved resident care and satisfaction.
  • Reduced staff turnover and increased retention.
  • Strengthened organizational culture and team dynamics.
  • Facility-wide certification signifying commitment to leadership and quality care.
  • Systems and resources to sustain the program and benefit future nurse leaders beyond the 2-year project period.

Core Competencies & Training Topics

  1. Leadership Fundamentals
      • Understanding leadership styles and self-awareness
      • Building engaged teams and fostering collaboration
  2. Supervisor Skill Building
      • Delegation of duties and task management
      • Conducting effective meetings and communication strategies
  3. LTC Survey Process and Regulations
      • Understanding and complying with LTC regulations
      • Navigating the LTC survey process
  4. Customer Service Excellence
      • Enhancing resident and family interactions
      • Addressing and resolving complaints effectively
  5. Clinical Systems Management
      • Implementing and monitoring clinical systems
      • Quality improvement and risk management
  6. Mentorship and Professional Development
      • Establishing mentor-mentee relationships
      • Career planning and ongoing professional growth

Project Overview

Project Outline

  1. Enrollment and Orientation
      • Facilities enroll in the program and attend an orientation session outlining the competency paths and completion requirements.
      • Facilities select individual nurse leader participants.
        • Identify nursing staff who demonstrate potential for leadership.
        • Ensure a mix of staff level participants (e.g., RNs, LPNs, nurse aides) to promote diverse perspectives and ensure the opportunity for entrance to the career pathway continuum.
        • Encourage participation from staff who demonstrate a commitment to professional growth and a passion for positively impacting resident care quality.
        • Should an individual participant leave the facility and/or project, facilities are encouraged to select a suitable replacement candidate(s) to join the project promptly to ensure continuity.
      • Select a Project Captain and Co-Captain who will champion the project.
  2. Module Participation
      • Individual nurse leader participants attend and actively engage in 12 training modules completed every other week.
      • Individual nurse leader participants complete and pass assessment for each module.
      • Complete associated assignments and practical activities.
  3. Mentorship Engagement
      • Individual nurse leader participants participate in 12 mentorship cohort meetings completed every other week on opposite weeks to the training modules.
      • Discussion on key leadership topics and opportunity for feedback from mentors and peers during cohort meetings.
      • Discuss training topics and work on related activities.
  4. Facility Career Pathway
      • Implement a Career Pathway using project resources or assess and update existing career pathway programs as indicated with mentor support.
  5. Staff Engagement
      • Complete a Staff Engagement Assessment to guide facility staff retention efforts.
  6. Project Implementation
      • Complete at least one leadership improvement project on topic of choice based on facility priority needs, e.g. mentorship program, welcome to the team program, career development program, 12-month staff engagement calendar,etc.  with guidance from mentor and cohort group
      • Individual nurse leader participants document and evaluate project outcomes.
      • Individual nurse leader participants review outcomes with the mentorship cohort.
  7. Exit Interviews and Replacement Process
      • Conduct exit interviews with departing staff to understand their reasons for leaving.
      • Use exit interview data to address any systemic issues within the facility.
      • Select and onboard replacement candidates for project participation using similar criteria to the initial selection process.
  8. Continuous Improvement
      • Facilities establish mechanisms for ongoing evaluation and improvement of leadership practices and system performance.
      • Implement retention strategies to keep nurse leaders engaged and motivated by customizing project resources for facility use including career pathway and development programming, recognition programs, staff engagement and team building activities, and fostering a supportive work environment.
  9. Final Reflection and Certification
      • Facilities report on leadership development/staff retention program progress, improvements, and future leadership goals. Facilities must demonstrate the successful implementation and integration of nurse leadership training and career pathway system improvements.
      • Review of facility outcomes report and approval of certification by project coordinators.
      • Receive the “Certified Leadership Excellence Facility” certification upon completion of all requirements.
      • Individual nurse leader participants will receive a certificate of project completion upon completing steps 2 (training modules) and 3 (cohort meetings), and after their facility has received the “Certified Leadership Excellence Facility” certification.

          Presented By:

          Shelly Maffia

          Shelly Maffia, MSN, MBA, RN, LNHA, QCP, CHC, CLNC, CPC
          Director of Regulatory Services

          Shelly Maffia is a Registered Nurse and licensed Nursing Home Administrator with extensive experience in the long-term care setting. She holds AANAC’s QAPI Certified Professional (QCP) credential, is certified in healthcare compliance through the Healthcare Compliance Association (HCCA), is an AAPC Certified Professional Coder (CPC), and is a Certified Legal Nurse Consultant. She is a member of the American Association of Legal Nurse Consultants (AALNC), the National Alliance of Certified Legal Nurse Consultants, the American Association of Professional Coders (AAPC), the American Association of Post-Acute Care Nursing (AAPACN), the American Health Information Management Association (AHIMA) and the Healthcare Compliance Association (HCCA). 

          Shelly specializes SNF regulatory compliance and nursing home quality improvement. She provides frequent consultation and training to nursing facilities across the nation on regulatory compliance, reimbursement compliance, and quality improvement. She has presented extensively on survey preparedness, QAPI, Achieving 5-Star QMs, Infection Prevention and Control, PDPM, and ICD-10-CM coding.

          She serves as the Director of Regulatory Services with Proactive Medical Review & Consultants, LLC.