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

Effective Date
11/2020
Document
Document
8607.pdf (304.87 KB)

 

Instructions

Updated: 10/2020

 

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 in which 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 beginning work in a long-term care facility.

Questions regarding 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 may 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 who is 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.

Section 3

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

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.

Certification and Signatures

If the person answers No to all of the questions in Sections 1-6, the managing local ombudsman 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 managing local ombudsman ensures the individual provides a detailed explanation of all Yes answers in the comments box. Based on the information provided, the managing local ombudsman determines if remedy or removal of the conflict is possible and submits Form 8613 as appropriate.