By Thomas Goldsmith

Millions in fines collected from poorly performing nursing homes across the country must by law be spent to improve conditions for long-term care residents. And according to federal regulators,  in North Carolina and other states have to spend the money they receive in those fines — or risk losing it.

North Carolina’s accumulation of fines has grown to $31.5 million by July 31 — from $28.9 million since the start of 2019 — even as state officials and others have pushed to increase the number of grants it sends to nursing homes.

“Oh, my goodness,” Louise Craig, 72, a resident of Trinity Elms, a nursing home in Clemmons, said upon learning of the fund. “We’ll take advantage of it if we can!”

Like many North Carolinians, Craig had never heard of the civil monetary penalties fund, although she receives the benefits from a $108,000 grant to NC Lutheran Services for Seniors, a nonprofit, faith-based health and social services organization that runs Trinity Elms. It’s paying for food-related amenities at seven affiliated nursing homes. 

Under the grant, residents enjoyed healthy smoothies during bingo hour last week and now have access to fresh-made paninis and Belgian waffles at a convenient kitchen. These extras help make Craig’s life in a facility not just bearable, but rewarding. Smoothies from fresh fruit may sound like a feel-good bonus, but they are being developed to enhance nutrition and help reduce residents’ intake of supplements such as Ensure.

“We want them to feel like if there’s something they want, that we can produce it,” said Mary Beth Lemly, administrator at Trinity Elms. “It’s no different from you or I walking into a restaurant and saying, ‘Ah, I feel like a hamburger today.’”

A bigger picture approach?

Advocates for older people and academics embrace the “culture change” grants like those at Trinity Elms. However, they argue that grants from this account should be parceled out more frequently, cover bigger issues, and be awarded based on an overall plan for better residents’ conditions. 

Philip Sloane, a family physician and geriatrician at UNC-Chapel Hill, said he and colleagues have received grants from the civil money penalties fund that have had positive benefit. An example is the Mouth Care Without a Battle program to train caregivers to perform oral care for people with physical and mental impairment. But he questions why regulators’ approach to picking projects seems so scattershot.

“I think that in some respects, it’s kind of kept under a bushel in that very few people know about [the grant money] and how to apply,” Sloane said. “Any money is important to spend well. Some better method of identifying and maybe even specifying what’s a reasonable use of these funds would be helpful.”

What can one grant provide?

N.C. Lutheran Services for the Aging won a $108,000 grant from the Centers for Medicare and Medicaid Services in December. In a letter to the Salisbury-based nonprofit, regulators said that the agency should provide its seven nursing homes with innovative means to make all residents’ dining experience better. That meant achieving the following goals, and more if needed.

  • “Increasing resident dining options and food choices;
  • “Decreasing the use of nutritional supplements; 
  • “Improving the aesthetics of pureed food entrees and overall food quality and presentation; and
  • “Improving the competency of food service workers in adhering to standardized recipes and planned menus, and the competency of members of the interdisciplinary team involved in all aspects of nutritional services.”
residents of nursing homes receiving grants from penalty payments enjoy a game of bingo.
Dorothy Sexton, 92, views a table of fresh-fruit smoothies and bingo cards at Trinity Elms nursing home in Clemmons. The treats, designed to lessen use of liquid supplements, were prepared with equipment supplied to the center by a grant from the Civil Money Penalties fund.

NC DHHS said in an emailed statement that the agency “is continuing to work with stakeholders including nursing home administrators and advocates for long-term care to encourage applications.”

DHHS noted that the federal Centers for Medicare and Medicaid Services has the authority to approve grants from the civil money penalties fund.

“Additionally we are working with those who apply to strengthen their grant proposals, thereby improving their likelihood of being approved by CMS,” the statement said. 

Polly Welsh, executive vice president of the N.C. Health Care Facilities Association, identified priorities that the nursing home industry would like to see put in place to benefit residents and facilities.

“We have to look at what we can do to increase the workforce,” Welsh said. Top of mind for her was creating training programs for personnel or creating a fund to pay off educational loans for that classwork. 

shows strawberries and bananas used at nursing homes receiving penalty money grants
Fresh strawberries are key to healthful smoothies that taste good, served at Trinity Elms nursing home in Clemmons. A grant from the Civil Money Penalties fund paid for necessary equipment. Photo credit: Thomas Goldsmith

“If we can get one person trained on working with our types or residents. Even if he moves to another town, it’s still there,” she said.

During this calendar year, state and federal regulators have stepped up the pace of awarding grants to nursing homes, with $722,000 dispensed so far this year, and at least 20 other grants under consideration, according to state DHHS.  

Two years ago, for all of 2017, N.C. grants totaled $106,000.

Picking up the pace

Advocates including Friends of Residents in Long Term Care say that a January 9 NC Health News article on the slow pace of spending the funds got the attention of legislators and officials at the state Department of Health and Human Services, with a resulting push toward approving more projects. Becky Wertz, section chief at the Division of Health Service Regulation, Nursing Home Licensure & Certification Section at the DHHS referred to the story in a recent email to members of the state Culture Change Coalition that helps solicit grants to be funded by the civil money penalties fund. 

“It caused concern with myself, Division leaders and the Department,” Wertz said in the email. “This is why I am always encouraging us to move these along as we need more and more approved grant proposals. 

“Also I had legislative people come and interview myself and (Division of Health Service Regulation deputy director) Emery (Milliken) about why we don’t issue out more grants.” 

Wertz also noted that the federal regulators could take a look at North Carolina’s fund at any time. 

“But, yes, the main reason is to benefit the residents and combat loneliness, boredom,” Wertz wrote.

Feds keep sharp eye out

Word is spreading in aging-issues advocacy circles about the federal scrutiny looming over this effort, which operates separately in every state. Earlier this year, inspectors from the U.S. Department of Health and Human Services took a harsh view of Michigan’s program because it only awarded grants from about two-thirds of the nursing home fines it assessed. 

In North Carolina, nursing homes paid nearly $14 million in fines in 2017, 2018 and the first four months of this year. And the money paid out was far less. In the Michigan case, the message sent by the federal DHHS was, in effect, use the civil money penalties (CMP) fund or lose it. 

Fruit in a metal spiral basket sitting on a countr
Lutheran Services for Seniors’ grant from penalty funds has made more fresh fruit into an option at its seven Piedmont facilities. Photo credit: Thomas Goldsmith

“If the Centers for Medicare and Medicaid Services (CMS) finds that a state has not spent CMP funds in accordance with regulations or fails to make use of funds, CMS may withhold future disbursements of CMP funds to the State,” the U.S. DHHS Inspector General’s office said in a February report

Sloane, the Chapel Hill doctor, says there’s enough money in the fund to bring about system-wide improvements with some changes in the process.

“That’s enough funding that they could put out a request for proposals and really try to do it in a serious way,” he said.

Lori Smetanka, executive director of the DC-based advocacy group National Consumer Voice, said improvements in the fund’s overall mission could mean that states improve their entire long-term care system instead of simply upgrading performance in individual nursing homes or small chains.

“I do think there should be transparency in how this money is used – not only for accountability but also in order to determine replicability of projects and to extend the benefits of the projects as widely as possible,” Smetanka said.

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Thomas Goldsmith

Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...