DHS does not survey 245D providers — a licensor conducts a licensing review and issues correction orders where the record does not support the requirement. The vocabulary differs from the MDH world, but the pattern is the same: a short list of findings accounts for most orders.
Here are the ones we see most across community residential services, adult foster care, integrated community supports and individualized home supports, and what actually prevents them.
1. CSSP addenda that no longer match the support plan
The support plan changes, the addendum does not, and the daily documentation follows neither. A licensor reads all three and the disagreement is immediate.
Tie the addendum to a change trigger: any support-plan revision, service change, or team meeting outcome starts a same-week addendum update with a signature date that follows the change, not precedes it.
2. Service documentation that records attendance, not outcomes
Notes that say the person 'had a good day' do not evidence the outcomes and methods the addendum promised. 245D documentation has to show what was worked on, how, and what happened.
Give staff a note template that mirrors the addendum outcomes for that person. When the note fields match the plan, the documentation gap closes itself.
- Progress reviews missing at the required interval
- Notes that never reference the outcome being supported
- Late entries with no indication of when the service actually occurred
3. Orientation, annual, and person-specific training records
245D expects documented orientation before a staff member works independently, annual training, and person-specific training for each person they support. The training usually happened; the record is thin.
One file per employee, with dates, topics, the trainer, and person-specific sign-offs listed by name. Being able to produce it in two minutes changes the tone of the review.
4. Incident reports with no internal review or trend analysis
Filing the report is only half the requirement. Licensors look for evidence that the program reviewed the incident internally and looked across incidents for patterns.
A short monthly review meeting with written notes satisfies this and, more usefully, catches the pattern before it becomes a maltreatment report.
5. Policies on the shelf and rights on the wall
The required 245D policy set exists but describes a program nobody runs. Service recipient rights are acknowledged at intake and never revisited in practice.
Policies should be written for your license type and your staffing reality, and rights should be something your staff can explain in plain language when a licensor asks.
6. Designated Manager and Designated Coordinator gaps
Qualification documentation missing, supervision cadence undocumented, or the named person no longer in the role. All three are straightforward orders to receive and straightforward to prevent.
Keep qualification evidence in the license file and log supervision the way you log training — dated, specific, and signed.
Frequently asked questions
Is a 245D licensing review the same as an MDH survey?
No. DHS licensors conduct licensing reviews and issue correction orders; MDH surveyors conduct surveys of 144G and 144A providers. The preparation overlaps, but the vocabulary, the process, and the response documents are different.
How far back do licensors sample?
Expect them to look across the current license period, and to pull both a long-standing person file and a recent admission.
What if we already have a correction order?
Respond to the system behind the order, not just the file that got cited. An order closed with a single-file fix tends to reappear at the next review.
Related service
Survey & licensing-review readiness
This article is general information for Minnesota providers, not legal advice. Requirements change — always confirm current expectations with the Minnesota Department of Health or the Department of Human Services before acting.
