Form DCF-2153 "Authorization Form for Private Facilities to Exceed Dcf Licensed Bed Capacity or Licensed Age Range" - Connecticut

What Is Form DCF-2153?

This is a legal form that was released by the Connecticut State Department of Children and Families - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 1, 2016;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DCF-2153 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-2153 "Authorization Form for Private Facilities to Exceed Dcf Licensed Bed Capacity or Licensed Age Range" - Connecticut

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Department of Children and Families
AUTHORIZATION FOR PRIVATE FACILITIES TO EXCEED DCF LICENSED BED CAPACITY OR
LICENSED AGE RANGE
DCF-2153
Page 1 of 3
5/16 (Rev.)
Approval to exceed DCF licensed bed capacity or the licensed age range can only be granted by the Regional Administrator of cognizance (or
designee) and the Agency Legal Director (or designee). Approval to exceed licensed bed capacity will only be given when the total number of
beds approved does not exceed the maximum established by Health and Fire Code permits and when there are no outstanding clinical or safety
issues that contraindicate a decision to exceed the licensed age range.
Note: The Careline Director (or designee) may grant approval after hours, in lieu of the Regional Administrator, until the next business day.
Waiver Requested For:
Over Licensed Bed Capacity
Outside Licensed Age Range
Emergency Bed Request
This Section to be completed by Area Office Staff for DCF-Involved Youth
Child’s Last Name:
Child’s First Name:
LINK #:
Person ID #:
Child’s DOB:
Child’s Race (as noted in LINK):
Child’s Ethnicity (as noted in LINK):
Please Select One
Please Select One
DCF Social Worker:
DCF Office:
Please Select DCF Office
Please provide a detailed description of the need for the waiver and the specific plans for discharge
including projected discharge date and discharge resource:
Name of DCF Staff Completing This Form:
Title:
Signature:
Date Completed:
Name of DCF Manager Approving Request
Title:
Signature:
Date Completed:
Department of Children and Families
AUTHORIZATION FOR PRIVATE FACILITIES TO EXCEED DCF LICENSED BED CAPACITY OR
LICENSED AGE RANGE
DCF-2153
Page 1 of 3
5/16 (Rev.)
Approval to exceed DCF licensed bed capacity or the licensed age range can only be granted by the Regional Administrator of cognizance (or
designee) and the Agency Legal Director (or designee). Approval to exceed licensed bed capacity will only be given when the total number of
beds approved does not exceed the maximum established by Health and Fire Code permits and when there are no outstanding clinical or safety
issues that contraindicate a decision to exceed the licensed age range.
Note: The Careline Director (or designee) may grant approval after hours, in lieu of the Regional Administrator, until the next business day.
Waiver Requested For:
Over Licensed Bed Capacity
Outside Licensed Age Range
Emergency Bed Request
This Section to be completed by Area Office Staff for DCF-Involved Youth
Child’s Last Name:
Child’s First Name:
LINK #:
Person ID #:
Child’s DOB:
Child’s Race (as noted in LINK):
Child’s Ethnicity (as noted in LINK):
Please Select One
Please Select One
DCF Social Worker:
DCF Office:
Please Select DCF Office
Please provide a detailed description of the need for the waiver and the specific plans for discharge
including projected discharge date and discharge resource:
Name of DCF Staff Completing This Form:
Title:
Signature:
Date Completed:
Name of DCF Manager Approving Request
Title:
Signature:
Date Completed:
Page 2 of 3
This Section to be completed by Staff from the Licensed Facility
Facility Name:
Facility Representative:
Title
Licensed Bed Capacity #:
Current Census #:
Health Capacity #:
Fire Capacity #:
Type of Facility:
Fax #:
Licensed Age Range:
Please Select One
From
To:
Estimated number of days over-census or over-age will be required:
Reason(s) for Request:
Facility concerns, if any:
Plan to return to licensed capacity or licensed age range:
Name of Provider Designee Making Request
Title:
Signature:
Date Completed:
APPROVALS: ALL REGIONAL ADMINISTRATORS WITH JURISDICTION OVER THE CHILD OR PLACEMENT MUST SIGN.
Name of DCF Regional Administrator (or designee):
Title:
Signature:
Date Completed:
Name of DCF Agency Legal Director (or Designee)
Title:
Signature:
Date Completed:
Name of DCF Careline Director (or Designee)
Title:
Signature:
Date Completed:
NOTE: IF FACILITY ANTICIPATES THAT CHILD WILL STAY BEYOND DISCHARGE
Waiver Expiration Date:
DATE, FACILITY MUST SUBMIT UPDATED WAIVER REQUEST BEFORE THAT DATE.
Copies:
Area Office
Careline
Facility
Facility Licensing Unit
Office of Legal Affairs
Page 3 of 3
INSTRUCTIONS
1.
A request for an over/under-age, over-census or emergency bed placement begins with the Area Office staff who is requesting the placement. Area Office
staff complete the first section of the form providing detailed information regarding the need for the waiver and the plans for discharge disposition, including
a discharge date. The DCF Area Office staff requesting the waiver must sign the form approving the waiver request submission and send it to the provider.
Note: Emergency beds are reserved solely for human trafficking victims or juvenile services clients. Use of these beds must be coordinated with the Director of
Multicultural Affairs and the Juvenile Services staff, respectively.
2.
The licensed provider must complete the second section of the form providing a clear plan for returning to their licensed bed capacity or licensed age range
and including any concerns that the facility has regarding the placement. The provider returns the form to the Area Office.
3.
The form includes space for the provider to comment on whether they think placement is appropriate.
If the facility does not wish to accept or extend the placement, the DCF Facilities Program Lead shall facilitate communication and resolution (in person or
on the phone) between the facility and AO staff who requested placement.
4.
The facility shall fax the waiver request to the Area Office for Regional Administrator approval. The Regional Administrator, or designee, shall gather
relevant information about the child and the facility if needed (special needs, discharge planning, etc.). If the placement is approved, the Regional
Administrator shall sign the form and transmit it to the Licensing Program Manager.
If the Regional Administrator or designee does not approve the placement, he or she shall notify the Licensing Program Manager. The Licensing Program
Manager shall notify the facility. The decision of the Regional Administrator is final.
5.
The Regional Administrator or designee shall send the signed form to the Licensing Program Manager:
Jim McPherson
Program Manager
DCF Licensing Unit
Office Phone: 860-550-6532
Cell Phone: 860-209-3192
Fax Number: 860-550-6665, OR,
After business hours, contact the Careline at fax 860-560-7072.
Careline approval is effective only until the next business day.
Careline shall fax the waiver to the Licensing Program Manager on the next business day.
6.
The Licensing Program Manager shall check for licensing concerns with the Licensing Regulatory Consultant and with DCF Risk Management. The
Licensing Program Manager shall email comments on the status of the facility's license and any other concerns about the status of the facility identified by
DCF Risk Management to the DCF Facilities Program Lead. The Licensing PM shall consult with a DCF Office of Legal Affairs Manager, as necessary.
7.
The Licensing Program Manager shall also notify the DCF Program Evaluation and Development Unit when appropriate.
8.
If the Licensing Program Manager approves the waiver, he or she shall sign the DCF-2153 and transmit it electronically to the Regional Administrator, or
designee, the DCF Facilities Program Lead and the provider with any notations such as the expiration date of the waiver. NOTE: All Regional
Administrators with jurisdiction over the child or the placement must be notified and sign the waiver, if approved. The Licensing Unit will keep copies of all
signed waivers.
If the Licensing Program Manager does not approve the waiver, he or she shall inform the Regional Administrator, or designee, and the DCF
Facilities Program Lead of the decision and the reasons.
If the Regional Administrator supports the waiver, and the Licensing Program Manager does not, both shall consult with a DCF Office of Legal
Affairs Manager with the goal of arriving at a consensus opinion.
9.
Waivers with expiration dates must be renewed prior to that date if the over/under-age child remains in the facility or the licensed bed capacity continues
to be exceeded.
10.
For cases not involved with DCF, e.g., privately placed clients, the licensed provider must complete the second section of the form and fax it to the DCF
Licensing Program Manager for review as indicated above.
Page of 3