Form 8609, State Long-Term Care Ombudsman Program Complaint for Regulatory Services Investigation

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Documents

Effective Date: 11/2019

Instructions

Updated: 6/2019

Detailed Instructions

Ombudsman Name — Enter your name, program, address, email address and telephone numbers (preferred and alternate).

Facility or Provider — Enter the name of the facility or provider, ID number and physical address.

Complaint/Problem description —

  • If the complaint is about a single event, enter the date and time; if the complaint is about a recurring situation, enter the dates and times.
  • Describe the problem and check the box for Nursing Facility or Assisted Living Facility.
  • Cite any state or federal regulations that apply.
  • Check whether you observed the event or situation, learned about it through interviews and/or by record review.
  • Indicate how often or how long the event or situation occurred.
  • Indicate whether the problem was isolated to a few residents or widespread affecting many residents.
  • Identify any actual or potential negative outcomes or injuries affecting physical or mental well-being of resident(s).
  • If you notified others, indicate whom.
  • State the desired resolution.

Resident (Ombudsman consent requirements apply) — Enter the resident's name. If the problem affected more than one resident, enter the primary resident's information and include other residents in Other information. Enter the room number or location, the resident's condition and care needs such as hospice, bedfast, ambulatory. If the problem relates to a financial issue, indicate the source of payment for care and, if applicable, the Medicaid number.

Person suspected as source of the problem (if applicable) — Enter the person's name and title, license type and license number if a specific person is alleged to have caused the problem.

Other information (Ombudsman consent requirements apply) — Enter the names of other people who might have information, such as family members or witnesses. Be prepared to share their contact information if known.

Ombudsman Program Documentation

Check Yes if supporting documentation is available and describe the documentation. If an ombudsman case record exists related to this complaint, the State Long-Term Care Ombudsman must approve release of that record. To file a complaint to Regulatory Services:

  • CRSComplaints@hhsc.state.tx.us
  • Notify the regional office of Regulatory Services that you submitted a complaint to.
  • Submit approved case records directly to the regional office of Regulatory Services.