245D documentation is what a Department of Human Services (DHS) licensor reads first and what a Minnesota Health Care Programs (MHCP) auditor reads second. The rules for home and community-based services (HCBS) providers licensed under Minn. Stat. chapter 245D put the record itself in § 245D.095, and the planning documents that fill it in § 245D.07 for basic support services and § 245D.071 for intensive support services.
The short answer: every person served needs a service recipient record with the items listed in § 245D.095, subd. 3. Within 15 days of service initiation the provider writes a preliminary support plan addendum. For intensive services, assessments and an initial planning meeting follow within 60 calendar days or 45 days of service, whichever comes first, and the plan is reviewed at least once a year. Daily service documentation has to prove the service was delivered as planned, because that is what the claim rests on.
This checklist is organized the way a review runs and reflects the statutes as of September 2026. If you are still deciding whether your services need the license at all, start with the 245D license guide.
Which statutes set 245D documentation requirements?
| Rule | What it covers |
|---|---|
| § 245D.095 | The service recipient record, admission and discharge register, access to records, personnel records |
| § 245D.07 | Person-centered planning principles; the 15-day and 60-day support plan addendum for basic services |
| § 245D.071 | Assessments, initial planning meeting, service outcomes, and progress reviews for intensive services |
| § 245D.04 | Written notice of service recipient rights within five working days and annually |
| § 245D.05 | Medication setup and administration records |
| § 245D.06, § 245D.061 | Incident reports and emergency use of manual restraint reports |
| Minn. R. 9505.2190 | Five-year retention of MHCP billing and health service records |
A note on terms. The statute now says "support plan" where providers still say coordinated service and support plan (CSSP), and "support plan addendum" for the CSSP addendum, which § 245D.02, subd. 4c defines as the documentation chapter 245D requires of the license holder for each person.
The 245D service recipient record checklist
§ 245D.095, subd. 3 requires a record of current services for each person, kept at the licensed facility or otherwise at the program office, and protected against loss, tampering, or unauthorized disclosure under the Minnesota Government Data Practices Act. The record must include:
- Admission form with identifying information: name, date of birth, address, and contact details for the legal representative, emergency contact, case manager, and family as applicable.
- Service information: the date of service initiation, verification of eligibility for the service, and documentation that services were delivered according to the support plan.
- Health information where the provider is responsible for it: medical history, dietary needs, allergies, medication orders, emergency authorization statements, medication administration records, and appointment schedules.
- The current support plan and support plan addendum, the individual abuse prevention plan, copies of assessments, and contact information for other service providers.
- Documentation of orientation to service recipient rights and to maltreatment reporting procedures.
- Copies of authorizations to handle the person's funds.
- Incident reports and documentation of complaints and how grievances were resolved.
- Progress or daily log notes recorded by the program and reports received from other agencies.
- Discharge summary with the service termination notice when applicable.
Subd. 2 separately requires an admission and discharge register.
Audit tip: licensors sample the record by date. If the support plan addendum on file is dated after the first billed service and there is no preliminary addendum, the finding writes itself. Keep dated versions, not just the current one. The common 245D licensing citations guide lists the other record findings licensors write up and how each is fixed.
Admission and service initiation records
- Rights notice within five working days. § 245D.04, subd. 1 requires a written notice identifying the service recipient rights and an explanation of them within five working days of service initiation and annually thereafter, with documentation that the person or legal representative received a copy.
- Abuse prevention plan. § 245D.071, subd. 2 requires the license holder to develop, document, and implement an individual abuse prevention plan under § 245A.65, subd. 2 prior to or upon initiating services.
- A copy of the support plan from the case manager, since the preliminary addendum is "based on the support plan."
- Medication authorization. If staff will administer medication, § 245D.05, subd. 2 requires written authorization before administration and the current prescription label or prescriber's order in the record.
Support plan addendum timelines: basic vs intensive services
Both categories start with the same 15-day step. Intensive services then add assessments, a planning meeting, and a formal outcomes plan with signatures.
| Step | Basic support services (§ 245D.07, subd. 2) | Intensive support services (§ 245D.071, subd. 3 and 4) |
|---|---|---|
| Preliminary support plan addendum | Within 15 calendar days of service initiation | Within 15 days of service initiation |
| Assessments (health and medical, personal safety, symptom or behavior self-management) | Not required by statute | Before 45 days of service or within 60 calendar days of initiation, whichever is shorter; reviewed annually or within 30 days of a written request |
| Initial planning meeting with the person and support team | Not required by statute | Same 45-day or 60-day window |
| Revised addendum documenting how, when, and by whom services will be provided | Within 60 calendar days of service initiation | Service plan with outcomes and supports within 10 working days of the planning meeting |
| Signatures | Participate in planning meetings on the support plan's timelines | Submit for dated signatures from the person or legal representative and case manager within 20 working days of the meeting; deemed approved if no response in 10 working days |
The assessments for intensive services must describe the person's overall strengths, functional skills and abilities, and behaviors or symptoms, and must be based on the person's status within the last 12 months. The basic vs intensive guide explains how to keep both sets of timelines straight when an agency provides both categories.
Person-centered planning requirements
§ 245D.07, subd. 1a requires services to be provided according to the support plan and addendum and to respond to the person's identified needs, interests, preferences, and desired outcomes. For intensive services, § 245D.071, subd. 3 lists what the initial planning meeting must cover: the scope of services, desired outcomes, the person's preferences, opportunities for integrated settings, skill development, community participation, relationships, employment, and coordination with other services. The meeting must also include a discussion of how technology might help the person meet desired outcomes, with a documented summary of decisions and any research still needed.
The service plan that follows under subd. 4 must document, for each desired outcome, the methods staff will use (including environmental modifications, equipment, and communication techniques), measurable and observable criteria for knowing when the outcome is achieved and how data will be collected, a projected start and review date, and the staff responsible. An outcome written as "improve independence" with no criteria is the most common planning finding.
Progress review reports and annual reviews
§ 245D.071, subd. 5 governs ongoing review. The license holder must give the person, legal representative, case manager, and anyone the person names an opportunity to participate in ongoing review of the service plan. Meetings follow the stated timelines in the support plan or addendum, and must happen at least once per year or within 30 days of a written request from the person, legal representative, or case manager.
For the meeting, the license holder must prepare a report that summarizes the person's status and progress toward the identified outcomes and recommends, with a rationale, whether to change, continue, or discontinue the supports and methods in the plan. After the meeting, the revised support plan addendum goes out within 10 working days, signatures are obtained within 10 working days, and changes are deemed approved if there is no response in 10 working days.
The statute's floor is annual. Many support plans set semi-annual or quarterly reviews, and once the schedule is in the plan it is the provider's deadline. Three other annual discussions must also be documented: technology use (subd. 5, para. (b)), options for moving out of a provider-controlled residential setting (para. (c)), and for day services, options for transitioning to employment services.
Service delivery documentation for billing
The record has to contain proof that services were delivered according to the support plan, and the claim has to match that proof. That means a service note or daily log for each date of service showing the date, the time or units, the staff person, the service provided, and its link to the outcomes in the plan. For 245D services that are also electronic visit verification (EVV) services, such as individualized home supports, the HHAeXchange visit data must match the note and the claim; see the EVV compliance checklist.
Medication records follow § 245D.05. Setup documentation must record the dates of setup, the medication name, dose quantity, administration times, and route. Administration records must note any dose not given or treatment not performed as prescribed, any adverse reaction, and when and to whom that was reported. Incident reports and emergency manual restraint reports belong in the record too; the 245D incident reporting guide covers their content and timelines.
Personnel documentation is part of the audit even though it lives outside the client record. § 245D.095, subd. 5 requires hire date, qualifications, training completion dates with hours and trainer names, performance evaluations, background study documentation, and the dates of first supervised and first unsupervised direct contact. The 245D training requirements guide lists what a licensor expects in that file.
Record retention and access
Chapter 245D does not set a retention period in years. The binding number for anything billed to MHCP is in Minn. R. 9505.2190, subp. 1: a provider must retain all health service and financial records related to a billed service for at least five years after the initial date of billing. Because a support plan addendum, assessment, or progress review is the documentation behind the claim, it falls under that rule.
The trigger is the initial billing date, not discharge, so a long-term client's records age out on a rolling basis. And the § 245D.095, subd. 3 duty to protect the record against tampering means an electronic system should keep an audit trail of who changed what and when. The DHS audit preparation checklist shows how to run a self-audit across those years.
How Trustora helps
Trustora's 245D record mirrors § 245D.095, subd. 3: admission information, rights acknowledgement, abuse prevention plan, support plan and addendum, assessments, medication records, incident reports, service notes, and discharge summary live in one client file with dated versions. The compliance engine tracks the 15-day preliminary addendum, the 45-day or 60-day assessment and planning window, the 10-working-day and 20-working-day plan steps, and each person's progress review schedule, and raises gap-day alerts before a deadline passes.
Service notes require the date, time, staff, service, and linked outcome before they can be filed, and the pre-claim gate checks that units and EVV data match the note before the claim is built. Records are retained on HIPAA-eligible AWS infrastructure with an append-only, SHA-256-chained audit log kept for seven years, which covers the five-year MHCP rule. See the platform overview for the 245D documentation workflow.