P008: Division of Health Improvement/Health Certification Licensing and Oversight

What We Do

The Division of Health Improvement (DHI) plays a critical role in improving the health outcomes and ensuring the safety of New Mexicans. DHI ensures that healthcare facilities, community based Medicaid waiver providers and community support services deliver safe and effective healthcare and community services in accordance with laws, regulations, and standards of practice.

Who We Serve

DHI works closely with key stakeholders to promote and protect the health, safety, and quality of life of New Mexicans. Our stakeholders include executive and legislative policy makers; providers; facilities and contractors; other state, local, and federal government agencies; advocacy groups; professional organizations; provider associations; various task forces and commissions; and the tax paying public at large.

How We Impact

Key DHI enforcement activities include: conducting various health and safety surveys for both facilities and community-based programs; conducting investigations of alleged abuse, neglect, exploitation, death or environmental hazards; and processing over 40,000 caregiver criminal history screenings annually.


FY18 OPERATING BUDGET: $12,047,500

  • General Funds: $4,192,600
  • Other Transfers: $3,348,400
  • Federal Funds: $2,613,000
  • Other State Funds: $1,893,500

During FY18, some of DHI's accomplishments included:

Caregiver's Criminal History Screening Program (CCHSP)

  • Processed 40,488 Caregiver Criminal History Screening Background Checks with an average processing time of one day.

Health Facility Licensing and Certification (HFLC)

  • Processed:  2,354 Certified Nurse Aide (CNA) Applications, over 1,400+ CNA reciprocity and verification requests, and 2,628 CNA renewal applications. 
  • Received and triaged over 15,000 reports regarding allegations of abuse, neglect, exploitation, injuries of unknown origin, and other reportable incidents in health facilities.
  • Received and processed 1,295 health facility hotline calls resulting in 195 onsite investigations being conducted.
  • The facility complaints unit completed 14,866 internal desk reviews of incidents.
  • Added four new Assisted Living Facility Surveyor positions.
  • Implemented a process to award quality improvement grants to health facilities by utilizing earmarked civil monetary penalty funds in partnership with Centers for Medicare and Medicaid Services (CMS).
  • Assisted in the approval of a CMS grant to provide funding to 20 New Mexico nursing homes for infection control improvement measures.
  • The Life Safety Code Team completed 269 surveys including:  112 recertifications, 88 revisits, 33 initials for new licenses, 30 initials for renovations, and 6 miscellaneous surveys. The plan review section received 108 building plans and approved 96 for new or renovation projects, and processed 159 plan reviews.

Community-Based Waiver Programs:

  • The online Abuse, Neglect and Exploitation (ANE) annual refresher training was activated on 3/1/18.  The online ANE refresher training is now available to all community-based service providers, Developmental Disabilities Supports Division and DHI staff.
  • The Incident Management Bureau  disengaged from Jackson Objective S1.1.2, regarding educating certain groups (i.e. families, guardians, physicians and law enforcement) about IMB and how to recognize and report abuse, neglect and exploitation.
  • The Quality Management Bureau completed a redesign and revisions of survey tools for community living, community inclusion and case management in conjunction with the new Developmental Disability Waiver standards.
  • The Individual Quality Review (IQR) survey team is fully staffed.


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