Form 8607, Conflict of Interest Screening of a Representative of the Office

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Documents

Effective Date: 9/2022

Updated: 01/2023

Purpose

To determine if an individual conflict of interest exists with a representative of the Office of the State Long-Term Care Ombudsman (Office). An individual conflict of interest is:

  • a situation where a person is involved in multiple interests, financial or otherwise, that could affect the effectiveness and credibility of the State Long-Term Care Ombudsman Program (Ombudsman Program; and
  • a conflict that involves a representative of the Office or an immediate family member of a representative of the Office.

Procedure

When to Complete

Obtain a completed and signed Form 8607:

  • for a job applicant before making a job offer;
  • for a volunteer applicant before the person performs functions of the Ombudsman Program;
  • annually for a current staff or volunteer of the Ombudsman Program;
  • when a staff or volunteer of the Ombudsman Program begins performing any of the activities identified as a potential conflict; and
  • when a relevant change occurs, such as an immediate family member moving into or starting work in a long-term care facility.

Questions about potential conflicts of interest include:

  • being involved with licensing or certifying an LTC facility, DAHS or HCSSA;
  • providing contract services, serving on a board or council, or working for a business that provides services to an LTC facility or a resident of an LTC facility;
  • having the right to receive payment from an owner or operator of an LTC facility;
  • being involved in making Medicaid, Medicaid managed care, Medicare, or PASRR decisions for someone other than an immediate family member;
  • receiving gifts, gratuities or other considerations from an LTC facility, a resident of an LTC facility, or a resident’s family;
  • owning or investment in an LTC facility, DAHS, HCSSA, personal care service, or business that makes referrals to an LTC facility;
  • managing or working for an LTC facility, DAHS, HCSSA, personal care service, or business that makes referrals to an LTC facility or managed care organization in Texas;
  • having a relative who lives or works in an LTC facility in Texas;
  • serving as a guardian, power of attorney, or primary decision-maker for a resident in an LTC facility; or
  • volunteering for an LTC facility, including serving on a board or council, providing religious services or consulting.

Form Retention

Retain the original completed form in the person’s certification file at the local ombudsman entity. Retain each subsequent form completed.

Submission to the Office

If a potential conflict is identified by answering “Yes” on the form, the managing local ombudsman (MLO) may either:

  • specify the names in the space provided in the gray section on this form, of any facility where the ombudsman is restricted from serving and it must be completed by the MLO; or
  • submit a removal or remedy plan for approval by the Office using Form 8613. If such a request is made, a copy of Form 8607 must accompany Form 8613.

Detailed Instructions

Name of person completing this form — type or print the name of the person being screened for a conflict of interest.

Section 1

This section applies to current circumstances and employment or action completed within the last 12 months. It includes a member of the person’s immediate family. Answer Yes or No to each question. If Yes, provide details of the circumstances.

Section 2

This section applies to current and past circumstances of the person. Answer Yes or No. If Yes, provide details of the circumstances.

Section 3

This section applies to current and past circumstances of the person. Answer Yes or No. If Yes, provide details of the circumstances.

Section 4

This section applies to current circumstances of the person. Answer Yes or No. If Yes, provide details of the circumstances.

Section 5

This section applies to current circumstances of the person. Answer Yes or No. If Yes, provide details of the circumstances.

Section 6

This section applies to current circumstances of the person. Answer Yes or No. If Yes, provide details of the circumstances.

Section 7 - This section must be completed by the MLO.

This section must be completed, signed, and dated by the MLO. This section lists long-term care facility placement restrictions for a representative of the Office, when applicable. Staff ombudsmen, including MLOs, may be required to submit facility placement restrictions on Form 8613. MLOs may not approve their own Form 8607. MLOs sign on the signature line labeled Ombudsman Intern or Certified Ombudsman.

Section 8: This section is completed by the Office for a representative of the Office who is an HHS employee and for any representative of the Office for whom a placement restriction is recommended.

This section is completed, signed, and dated by the State Long-Term Care Ombudsman or Designee. If a placement restriction is not approved, the MLO must submit HHSC Form 8613 to the State Ombudsman for approval.

Certification and Signatures

If the person, other than an MLO, answers No to all of the questions in Sections 1-6, the MLO signs the form and retains a copy of the form in the person’s certification file.

If the person answers Yes to one or more of the questions in Sections 1-6, the MLO ensures a detailed explanation of all Yes answers is provided in the comments box. Based on the information provided, the MLO determines if remedy or removal of the conflict is possible and lists facility placement restrictions on this form in the space provided or submits to the Office Form 8613 as appropriate.