245D person-centered planning is the process that turns a case manager's plan into a provider's plan. Minn. Stat. § 245D.07, subd. 1a requires every home and community-based services (HCBS) license holder to deliver services in response to the person's identified needs, interests, preferences, and desired outcomes. § 245D.071 adds the assessments, planning meeting, measurable outcomes, and reviews that intensive support services must complete.
Two documents are involved. The coordinated service and support plan (CSSP), which the statute now calls the support plan, is the case manager's plan for all of the person's services. The CSSP addendum, now the support plan addendum, is what the 245D license holder writes to say how, when, and by whom it will deliver its part. Every provider completes a preliminary addendum within 15 days of service initiation; intensive services then have 45 days of service or 60 calendar days to assess and meet, 10 working days to write outcomes, and 20 working days to collect signatures.
This guide covers the two documents, the state and federal person-centered principles, the timelines, the required contents, outcomes and reporting, the annual meeting, and a template outline, as of September 2026. For the categories the timelines depend on, see 245D basic vs intensive support services.
The CSSP and the addendum: who writes what
| Document | Statute | Author | Purpose |
|---|---|---|---|
| Support plan (CSSP) | § 245D.02, subd. 4b, pointing to §§ 256B.0913, 256B.092, 256B.49, and 256S.10 | The case manager | The person's overall plan across all waiver services and providers |
| Support plan addendum (CSSP addendum) | § 245D.02, subd. 4c | The 245D license holder | The documentation chapter 245D requires of the provider for each person: scope, outcomes, supports, methods, and responsibilities |
| Service plan | § 245D.071, subd. 4 | The 245D license holder | For intensive services, the outcomes and supports section that must be included in the addendum |
The addendum is "based on the support plan," so the provider needs the current support plan before writing the preliminary addendum, and when the support plan changes the addendum has to follow.
Person-centered principles in § 245D.07 and the HCBS settings rule
Section 245D.07, subd. 1a(b) sets three principles the addendum must reflect. Person-centered planning identifies and supports what is important to the person as well as what is important for the person, respects the person's history and cultural background, and uses the person's preferences to identify desired outcomes. Self-determination provides opportunities to develop and exercise functional and age-appropriate skills, decision making, and choice while protecting civil and legal rights. Integrated settings provide inclusion and participation in the community as the person desires, with opportunities for self-sufficiency and a balance between risk and opportunity.
The federal rule at 42 CFR 441.301(c) applies to every waiver service a 245D provider bills and says the same thing in more detail.
| Federal element (42 CFR 441.301(c)) | Where it lands in 245D |
|---|---|
| A planning process led by the individual, with people the person chooses, at convenient times and places, in plain language, with conflict-of-interest guidelines (c)(1) | The planning meeting invitees in § 245D.071, subd. 3(c) and the person's preferences for how services are provided |
| A plan reflecting the setting the person chose, strengths and preferences, assessed needs, goals and desired outcomes, paid and natural supports, and risk factors with backup plans (c)(2) | The § 245D.071, subd. 3(c) topics and the subd. 4 outcomes and supports |
| Review at least every 12 months, on significant change, or at the person's request (c)(3) | The annual review and 30-day written request rule in § 245D.071, subd. 5 |
| Settings conditions for provider-owned or controlled residential settings, and documented modifications with assessed need, prior interventions, data, time limits, and informed consent (c)(4)(vi) | Any restriction in a community residential or integrated community supports setting, documented in the addendum |
Timelines: 15 days, 45 or 60 days, 10 and 20 working days
| Step | Basic support services | Intensive support services |
|---|---|---|
| Preliminary support plan addendum | Within 15 calendar days of service initiation (§ 245D.07, subd. 2(b)) | Within 15 days of service initiation (§ 245D.071, subd. 3(a)) |
| 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, whichever is shorter (subd. 3(b)) |
| Initial planning meeting | Participate in team meetings on the support plan's timelines (subd. 2(d)) | Same 45-day or 60-day window (subd. 3(c)) |
| Outcomes and supports | Revised addendum within 60 calendar days documenting how, when, and by whom (subd. 2(c)) | Service plan within 10 working days of the meeting (subd. 4(a)) |
| Signatures | None specified | Submit for dated signatures within 20 working days of the meeting; deemed approved after 10 working days without response (subd. 4(c)) |
The assessments must describe the person's overall strengths, functional skills and abilities, and behaviors or symptoms, must be based on the person's status within the last 12 months, and must be repeated at least annually or within 30 days of a written request. The 245D documentation checklist shows how to date each step in the record.
What the support plan addendum must contain
For intensive services, § 245D.071, subd. 3(c) lists what the planning meeting must determine, and those determinations become the addendum's content:
- The scope of services to support the person's daily needs and activities.
- The person's desired outcomes and the supports necessary to accomplish them.
- The person's preferences for how services are provided, including how the provider will support the person's control of the person's schedule.
- Whether the current setting is the most integrated setting available and appropriate.
- Opportunities to develop and maintain essential and life-enriching skills, abilities, strengths, interests, and preferences.
- Opportunities for community access, participation, and inclusion.
- Opportunities to develop and strengthen personal relationships.
- Opportunities to seek competitive employment.
- How services are coordinated across other 245D providers and the support team.
Subd. 3(d) adds a summary of the technology discussion, including any decision made and any research still needed. Other sections push content into the same document. Under § 245D.05, subd. 1(b), when health service needs are assigned to the license holder, the provider documents how they will be met, including medication procedures; see the 245D medication administration guide. Under § 245D.051, subd. 1(b), a psychotropic medication requires a description of target symptoms and the monitoring method in the addendum. Under § 245D.071, subd. 2, an individual abuse prevention plan under § 245A.65, subd. 2 is developed before or upon service initiation. And any modification of the federal settings conditions must be documented with the eight elements in 42 CFR 441.301(c)(4)(vi)(F).
Compliance note: "outcome" is a defined piece of work, not a heading. An addendum that lists "increase independence in the community" without criteria, a data method, a review date, and a responsible staff name fails § 245D.071, subd. 4(b) on its face, no matter how person-centered the narrative reads.
Measurable outcomes and how progress is reported
Subd. 4(b) requires four things for every outcome: the methods or actions staff will use, including environmental changes, equipment and materials, and techniques matched to the person's communication mode and learning style; the measurable and observable criteria for identifying when the outcome is achieved and how data will be collected; the projected start date and the date progress will be reviewed; and the names of the staff or position responsible.
A workable outcome reads like this: "By March 31, [name] will prepare a simple breakfast with no more than one verbal prompt on four of five weekday mornings, recorded on the daily prompt log by the morning support staff." The criterion is observable, the data source is named, the date is set, and the role is assigned.
Reporting then follows the data. Under subd. 5(g), the license holder must summarize the person's status and progress toward each outcome and recommend, with a rationale, whether to change, continue, or discontinue each support and method, in a report available at the progress review meeting and sent at least five working days ahead if the team requested that in the plan. For basic support services, § 245D.07, subd. 3 requires written progress or status reports whenever the person, legal representative, case manager, or team asks.
The annual meeting and the 30-day written request rule
Under § 245D.071, subd. 5(a), the license holder must participate in service plan review meetings following the timelines in the support plan or addendum, at least once per year, or within 30 days of a written request from the person, the legal representative, or the case manager. The review decides whether the plan needs to change based on the assessments, the provider's evaluation of progress, and the team's input.
The same annual meeting carries three other required discussions, each summarized in the addendum: how technology might help meet desired outcomes (para. (b)); for residential services, options for moving out of a provider-controlled setting (paras. (c) and (d)); and for day services, options for transitioning to an employment service (paras. (e) and (f)).
After the meeting, the addendum is mailed to the person, legal representative, and case manager within 10 working days, dated signatures are obtained within 10 working days of mailing, and a submission that is neither signed nor modified within 10 working days is deemed approved (paras. (h) and (i)). The what is 245D guide explains where these planning duties sit within the chapter.
A support plan addendum template outline
- Identification. Person, date of service initiation, service and its § 245D.03 category, case manager, legal representative, support team members, and the support plan version this addendum is based on.
- Preliminary addendum (day 15). Services to be provided, how, when, and by whom, taken from the support plan.
- Assessments (intensive). Health and medical, personal safety, and symptom or behavior self-management, with the date and the 12-month status basis.
- Planning meeting summary. Date, attendees, and the nine subd. 3(c) determinations plus the technology summary.
- Outcomes and supports. One block per outcome with methods, criteria, data collection, start and review dates, and responsible staff.
- Health, medication, and risk. § 245D.05 procedures, § 245D.051 target symptoms, the abuse prevention plan reference, and any settings modification with its (c)(4)(vi)(F) elements.
- Signatures. Dated signatures of the person or legal representative and case manager, with submission and deemed-approval dates.
- Reviews. Each progress review report, meeting date, changes, and the post-meeting mailing and signature dates.
How Trustora helps
Trustora's 245D client record holds the support plan from the case manager and the provider's support plan addendum as dated versions, with the preliminary addendum, assessments, planning meeting summary, outcomes, and reviews as structured sections rather than a single narrative. Each outcome requires methods, measurable criteria, a data collection method, start and review dates, and a responsible staff role before it can be saved, and daily service notes link to an outcome so progress data accumulates for the review report.
The compliance engine starts the 15-day, 45-days-of-service or 60-calendar-day, 10-working-day, 20-working-day, and annual review clocks from the service initiation date and raises gap-day alerts before each one, and the one-click DHS audit binder produces the dated planning chain for any person. See the platform overview for the 245D planning workflow.