Form 8613, Office of the State Long-term Care Ombudsman Conflict of Interest Identification, Removal and Remedy

Instructions

Purpose

• To request approval by the State Long-Term Care Ombudsman of a plan to remedy or remove an individual conflict of interest with a representative of the Office of the State Long-Term Care Ombudsman (Office). An individual conflict of interest is a conflict regarding a representative of the Office or an immediate family member of a representative of the Office.
• To remove an organizational conflict of interest that affects a local ombudsman entity. An organizational conflict of interest is a conflict within a host agency, or governmental entity or nonprofit organization contracting with a host agency, to perform the functions of a local ombudsman entity.

Procedure

When to Complete

When requesting approval of a remedy or removal plan by the State Ombudsman. This approval is required for a person or local ombudsman entity with an identified conflict to perform functions of the Ombudsman Program. Complete the form within the following time frames:

• before making a job offer for an identified conflict regarding a job applicant;
• before the person performs functions of the Ombudsman Program for an identified conflict regarding a volunteer applicant;
• within five days of identifying the conflict regarding a managing local ombudsman;
• within 30 days of identifying the conflict regarding a staff or volunteer ombudsman other than a managing local ombudsman; and
• within 30 days of identifying the conflict for a local ombudsman entity with an organizational conflict.

Form Retention and Submission

Submit Form 8613 to the State Long-Term Care Ombudsman via mail, email, or fax. The Office provides a copy of an approved request to the local ombudsman entity by email. Submit and retain a copy of the form as follows:

• For individual conflicts of interest other than the managing local ombudsman, the managing local ombudsman submits the form to the Office for approval. If approval is given, retain a copy of the approved form at the Office and local ombudsman entity. Provide a copy to the individual with an identified conflict.
• For individual conflicts of interest regarding the managing local ombudsman, the host agency representative submits the form to the Office for approval. If approval is given, retain a copy of the approved form at the Office and local ombudsman entity, and host agency.
• For organizational conflicts of interest, the host agency submits the form to the Office for approval. If approval is given, retain a copy of the approved form at the Office, local ombudsman entity and host agency.

Detailed Instructions

Name of person completing this form — type or print the name of the person who is completing the form.

• If Individual is selected, enter the name of the individual with the conflict.
• If Organizational is selected, enter the name of the entity or entities with a conflict.

Section 1

Describe the conflict in detail.

Section 2

Describe the scope of the conflict. Specify organizations and businesses affiliated with the conflict, including businesses operated by the same owner.

Section 3

Identify functions that require changes to Ombudsman Program procedure, including the following functions as applicable:

• ombudsman intake procedures;
• contact with residents;
• communications with providers, facility staff, owner, or host agency staff;
• complaint-handling procedure;
• employment or volunteer responsibilities within the local ombudsman entity; and
• other changes.

Section 4

Describe how the conflict will be remedied or removed. Address each issue noted in Section 3, and the following as applicable:

• if the conflict is a current or previous financial relationship with a long-term care facility, say how this relationship will not negatively impact the Ombudsman Program;
• if a current or previous personal relationship with one or more residents in a long-term care facility, say how this relationship will not negatively impact the ombudsman's role as an advocate for all residents in the assigned facility or facilities;
• if the conflict involves membership or volunteer activities relating to long-term services and supports, say how the activity will not negatively affect the Ombudsman Program; and
• if an organizational conflict, address all functions affected by the conflict.

Section 5

State the name and title of the person to whom the individual or local ombudsman entity will report for supervision within the host agency. Describe how the arrangement will be monitored for effectiveness.

Section 6

Explain how long the conflict and plan are expected to exist. Address how and when the plan will be monitored for effectiveness.

Section 7 Signatures

For individual conflicts of interest other than the managing local ombudsman, the applicant or ombudsman and the managing local ombudsman sign and date the form.

For individual conflicts of interest regarding the managing local ombudsman, the applicant or managing local ombudsman and host agency representative (supervisor) sign and date the form.

For organizational conflicts of interest, the managing local ombudsman and host agency representative sign and date the form. 

Section 8 Decision by State Ombudsman

The State Ombudsman answers Yes or No, and may include additional information in the Note field. If modifications to the plan are required, the State Ombudsman documents modifications in the Modifications field. Modifications may include time limits, additional requirements, and other direction by the State Ombudsman.

The State Ombudsman signs and dates the plan to indicate approval.