Effective Date
Instructions
Updated: 9/2025
Purpose
Determines 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 has many 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
Get 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
Keep the original completed form in the person’s certification file at the local ombudsman entity. Keep completed subsequent form.
Submission to the Office
If a potential conflict is identified by answering Yes on the form, The State Long-Term Care Ombudsman Program may:
- Restrict the facility locations where you are assigned to avoid a conflict.
- Require the MLO to submit a remedy plan to the state ombudsman.
Detailed Instructions
Section 1 – Person Information and Questions
Name of person completing this form — type or print the name of the person being screened for a conflict of interest.
1. This section concerns current and past circumstances of the person. Answer Yes or No. Provide details of the circumstances if yes.
2. This section concerns current and past circumstances of the person. Answer Yes or No. Provide details of the circumstances if yes.
3. This section concerns current and past circumstances of the person. Answer Yes or No. Provide details of the circumstances if yes.
4. This section concerns 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. Provide details of the circumstances if yes.
5. This section concerns current circumstances of the person. Answer Yes or No. Provide details of the circumstances if yes.
6. This section concerns current circumstances of the person. Answer Yes or No. Provide details of the circumstances if yes.
7. This section concerns current circumstances of the person. Answer Yes or No. Provide details of the circumstances if yes.
8. This section concerns current and past circumstances of the person. Answer Yes or No. Provide details of the circumstances if yes.
Applicant’s Certification of if any Question Indicates a Conflict of Interest
The person completing the form selects option 1 or option 2.
Select Option 1 if you answered no to every question. No conflict was identified.
Select Option 2 if you answered yes for any question. You have identified a potential conflict.
Ombudsman Intern or Certified Ombudsman Signature Line
The person completing the form must sign and date this section.
Section 2 – For MLO Use Only
The MLO must complete, sign and date this section. This section lists volunteer ombudsman location restrictions, when applicable. MLOs sign on the signature line labeled Managing Local Ombudsman and select the date.
Section 3 – For State Office Section Use Only
The Office completes this for a representative of the Office who is an HHS employee and for any representative of the Office for whom a location restriction is recommended.
The State Long-Term Care Ombudsman or Designee completes, signs and dates this section. The MLO must submit HHSC Form 8613 to the State Ombudsman for approval if a placement restriction is not approved.
Certification and Signatures
The MLO:
- signs the form and keeps a copy of the form in the person’s certification file if the person, other than an MLO, answers No to Questions 1-8;
- ensures a detailed explanation of all Yes answers is provided in the comments box if the person answers Yes to one or more of Questions 1-8;
- determines if remedy or removal of the conflict is possible; and
- lists facility location restrictions for a volunteer on this form in the space provided or submits to the Office Form 8613 as appropriate based on the information provided.