Division of Health Improvement
The Department of Health’s Division of Health Improvement (DHI) is the regulatory entity providing compliance oversight for the following areas.
- Licensed health facilities such as: non-long term care, long-term care, assisted living home care and hospice, free standing birth centers, community mental health centers and other facilities.
- Home and community-based Medicaid waiver providers for the Developmental Disabilities Waiver, Medically Fragile Waiver and the Mi Via Waiver.
- Conducts investigations of Abuse, Neglect & Exploitation for licensed health facilities and home and community-based Medicaid waiver programs.
- Operates the Caregivers Criminal History Screening Program (CCHSP) which provides criminal background checks on potential caregivers.
- Operates the Employee Abuse Registry (EAR) also known as, the Consolidated Online Employee Abuse Registry (COR) which provides background checks for all caregivers, ensuring they have not been disqualified by a substantiated case of ANE. Individuals placed on the EAR are not eligible for hire as caregivers.
- Operates the Certified Nurse Aide Registry (NAR) and Training program.
- Certifies all clinical laboratories operating in New Mexico meet health and safety requirements.
NEW : Long Term care Letter of Direction - DHI Memo - Letter of Direction - 12/05/2022
Voting Rights for Long Term Care Residents
Special Announcement:
In order to prepare for this anticipated influx of applications,
"In an effort to provide support to workplaces who may be doing COVID-19 testing, CMS has prepared materials to outline the simple steps necessary to do this. Generally, a CLIA certificate of waiver is necessary for a workplace to do testing. For information regarding CLIA requirements and the application process for workplace COVID-19 testing, please see the Quick Start Guide for COVID-19 Testing in the Workplace and the Workplace COVID-19 Testing Fact Sheet.
PLEASE NOTE: CMS is temporarily exercising enforcement discretion and allowing employers to start waived SARS-CoV-2 Point of Care testing after a facility has submitted a CMS-116 application.
Background Checks for Community Based Waiver Service Providers and Support Caregivers
Effective January 1, 2022, via this notice, all new hired “caregiver” employees of licensed health facilities and home and community-based Medicaid waiver programs who are defined as a “caregiver” (see 29-17-4 NMSA and 7.1.12.2 NMAC) and hired on or after January 1, 2022, shall be in compliance with 29-17-2 et seq and 7.1.12 NMAC and complete a background check at time of hire.
See memo Background Check Supplement for complete details regarding background checks for caregivers hired between April 1, 2020 and December 31, 2021 Any caregiver hired during the public health emergency and has not had a fingerprint background check must come into compliance by March 31, 2022.
Enforcement Activities
DHI enforcement activities include:
- Surveys — Conducting health & safety surveys for both health facilities and community based waiver programs.
- Visit the Health Facility Provider Search page to search the licensed healthcare facility survey reports.
- Visit the Developmental Disabilities Waiver Survey Unit, Medically Fragile Waiver Survey Unit and Mi Via Self-Directed Waiver Survey Unit pages to view completed surveys and past performance of providers.
- Investigations — Conducting investigations of alleged Abuse, Neglect & Exploitation, suspicious or unknown injures, death or environmental hazards in waiver programs and health facilities.
- Compliance — Ensuring caregivers have required Background Checks and screenings, and ensuring compliance with other statutes, rules and regulations.
Health facilities and community based waiver programs found out of compliance may be subject to civil monetary penalties or other sanctions as authorized by Centers for Medicare and Medicaid Services or state law.
Organizational Structure
The Division of Health Improvement consists of 162 staff members located in 4 field offices across New Mexico with a central office in Santa Fe. Our staff have a variety of professional and educational backgrounds and experiences. Many are licensed as psychologists, nurses, physicians, life safety code engineers, architects, social workers and other related fields, who hold bachelor's, master's, and doctoral degrees. We are organized into the following three areas.
- Health Facility Licensing and Certification – Consists of District Operations which conducts surveys, and Program Operations which administers the facility licenses and services such as the Nurse Aide Registry.
- Community Based Waiver Programs – Consists of Incident Management and Quality Management.
- Director’s Office – Consists of DHI Administrative Services, Human Resources and the Office of Policy, Planning & Performance Improvement.
Please see the Human Resources section of our website for a list of Job Opportunities with Division of Health Improvement and obtain our latest organizational chart.
Health Facility Guidance during Covid-19
- LTC Guidance on 2nd Booster Clinic Scheduling
- LOD Vaccination Data Reporting 2.25.22
- LTC Testing Guidance updated 2.07.22
- LTC LOD Addendum 2.07.22
- COVID Therapeutics for Long Term Care Prescribers 2.02.22
- Temporary Volunteer Guidance 10.07.21
- COVID-19 Testing Guidance for Home Health and Hospice Providers — Testing and Documentation Protocol for Home Health and Hospice Providers in Long-Term Care Facilities.
- SARS-CoV-2 virus Guidance for Long-Term Care Providers and administrators Sept 28,2020 — Directives and guidance for Long-Term Care Facilities.
- ICF Testing Guidance
- ICF/IID Visitation Quarantine Activity Guidance
- Home Health and Hospice Letter of Direction updated July 9th,2021
- LTC Home Health / Hospice Guidance updated 12-14-2021
- Crisis Staffing Instructions
- Holiday FAQ's 10.20.2021
- COVID-19 In-Person Visitation Application Template
- COVID-19 In-Person Visitation Application FAQ
- Resolution of the New Mexico Department of Health State of New Mexico Medical Advisory Team
Customer Satisfaction Surveys
Has your health facility recently been surveyed by the Division of Health Improvement? If so, we would like to know how we performed.
- Health Facility Customer Satisfaction Survey
- Community-Based Waiver Provider Customer Satisfaction Survey
- Incident Management Bureau — Please send IMB customer feedback directly to Edward Stallard.
Regulations
Please visit the Regulations page for a complete listing of the rules and regulations which govern the majority of what we do.
The Department of Health’s Division of Health Improvement has issued a new regulation on Boarding Homes effective June 3, 2020. To Access the new rule please see the 7.8.4 General Requirements for Boarding Homes
The Division of Health Improvement has Issued a new Regulation for all caregivers in Long term care facilities to have additional dementia training NMAC 7.1.32
New Emergency Rule and Pending Regulations
The Department of Health Division of Health Improvement has no emergency rules in effect at this time or pending rule changes. Be sure to visit our Regulations page to view recent updates made to existing rules.
See revisions to NMAC 7.28.2 Requirements for Home Health Agencies effective November 10th, 2020
The Division of Health Improvement has Issued a new Regulation for all caregivers in Long term care facilities to have additional dementia training NMAC 7.1.32
Notice of Public Hearing
The Division of Health Improvement has no public hearings scheduled at this time for new or existing rules.
Quick Links
Community Programs
- Incident Management Bureau Annual Report SFY20
- Community Programs ANE Reporting Guide for SFY21 (English version)
- Incident Management Bureau Annual Report SFY19
- Incident Management Bureau Annual Report SFY18
- Incident Management Bureau Annual Report SFY17
- Incident Management Bureau Annual Report SFY16
- Incident Management Bureau Annual Report SFY15
- Community Program ANE Reporting Guide (Abuso, Negligencia y Explotación Información Guía)
- Community Program ANE Reporting Form
- Immediate Action Safety Plan
- Abuse, Neglect & Exploitation Reporting Poster for Community Programs
- NMAC 7.1.14 — ANE and death reporting, training, and related requirements for community providers.
Community Provider Survey Report of Findings
- Living Supports, Community Supports and Employment Services Report of Findings
- Case Management Services Report of Findings
- Medically Fragile Waiver Survey Unit Report of Findings
- Mi Via Self-Directed Waiver Survey Unit Report of Findings
Community Provider Survey Report of Findings
- Living Supports, Community Supports and Employment Services Report of Findings
- Case Management Services Report of Findings
- Medically Fragile Waiver Survey Unit Report of Findings
- Mi Via Self-Directed Waiver Survey Unit Report of Findings
Field Tools
Please visit the Field Tools page to explore the various field tools such as Case Management, Living Care and Arrangements, and Community Inclusion.
ANE Training for Community Providers
- Abuse, Neglect & Exploitation Required Training Director's Release
- Abuse, Neglect & Exploitation Provider Training
Licensed Health Facilities
- ICF/IID Visitation Quarantine Activity Guidance
- ICF Testing Guidance
- "NEW" Home Health and Hospice Directives 02/04/2021
- Health Facility Consumer Complaint Form — Fax number and mailing address are in the form.
- Health Facility Reporting System
- Incident Management System Guide for all Licensed Health Care Facilities SFY2023
- Health Facility Consumer Complaint Form
- Health Facility Complaint Investigation Five Day Follow-up Report Form
- Abuse, Neglect & Exploitation Reporting Poster for Health Facilities
- Abuse, Neglect & Exploitation Reporting Tribal Phone Numbers
- NMAC 7.1.13 — Incident Reporting, Intake, Processing & Training Requirements for Facilities
Search Licensed Health Facilities Survey Report of Findings
Search Medicare Nursing Home Compare
Nursing Home Compare provides details on nursing homes across the country. This includes nursing home inspection results, staffing levels, enforcement actions that the federal government have taken against the nursing homes and how well nursing home residents were treated in specific areas of care.
News Articles
Latest
- DOH provides tips and resources for managing mental health during the holiday season (December 21, 2022)
- State announces first four winners of Vax 2 the Max sweepstakes (July 22, 2021)
- New Mexico COVID-19 update: 122 new cases, totaling 204,392 (June 15, 2021)