The most common 245D licensing citations and how to avoid them

245D licensing citations are what a Department of Human Services (DHS) licensor writes when a sampled record does not match a requirement in Minn. Stat. chapter 245D or the licensing act in chapter 245A. The order is public on the DHS Licensing Information Lookup, and uncorrected or repeated citations lead to a conditional license, fines, or worse under § 245A.07.

DHS does not publish a ranked list of 245D findings, and this guide does not invent one. It lists the areas licensors cite, drawn from the requirements a licensing review checks and from public correction orders on the lookup, including two 2024 orders to 245D license holders. For each area it gives the statute, what the licensor looks for, and the fix, then explains the correction order process as of September 2026. If you are new to the chapter, what 245D is covers the framework.

How a 245D licensing review works

A licensing review is a records review before it is anything else. The licensor states the standards reviewed (chapter 245D, chapter 245A, chapter 245C for background studies, and Minn. R. chapter 9544 where positive supports apply), then samples service recipient records, personnel files, incident and restraint reports, and policies. DHS has committed to reviewing every licensed 245D provider at least once every three years.

The outcome is one of four: no violations; a correction order; a correction order with a conditional license; or, for serious or repeated problems, a fine, suspension, or revocation. The DHS audit preparation checklist covers how to run the same sample on yourself first.

The areas licensors cite, with the statute and the fix

1. Support plan addendum late or missing

§ 245D.07, subd. 2 requires a preliminary support plan addendum within 15 calendar days of service initiation and a revised addendum within 60 calendar days. Fix: start both clocks from the service initiation date and keep the dated preliminary version, not just the current one. The 245D documentation checklist lists what each version must contain.

2. Assessments and the initial planning meeting outside the window

For intensive services, § 245D.071, subd. 3 requires three assessments and an initial planning meeting before 45 days of service or within 60 calendar days, whichever is shorter. The August 2024 order cites paragraph (c), the required discussion of how technology might help the person meet outcomes. Fix: use a meeting template that includes every subd. 3 topic, and count days of service, not only calendar days.

3. Outcomes without criteria and progress reviews off schedule

Subd. 4 requires measurable and observable criteria for each outcome and signatures within 20 working days; subd. 5 requires review meetings on the support plan's schedule, at least once a year or within 30 days of a written request, with a written progress report. Fix: make criteria and the data collection method required fields, and calendar each person's review date from the support plan.

4. Staff orientation not documented within 60 days

§ 245D.09, subd. 4 requires orientation on 11 topics within 60 calendar days of hire, and the August 2024 order cites it for two of six staff sampled. The licensor wants a date, hours, and trainer for each topic. Fix: track each topic per staff person and record first supervised and unsupervised contact dates the day they happen. The 245D training guide shows the full record.

5. Missing annual training

Subd. 5 requires annual training on clauses (3) to (11). The common gap is a staff person whose orientation was complete but whose anniversary passed without a session. Fix: set the anniversary from the prior training date and treat first aid expiration as a compliance date.

6. Background study not completed before direct contact

Chapter 245C requires a study submitted through NETStudy 2.0 before an individual begins a position allowing direct contact, and § 245C.03 covers controlling individuals. The August 2024 order cites a controlling individual with no study. Fix: make the study a gate in onboarding, and re-check the list of controlling individuals whenever ownership or management changes.

7. Incident reports not sent within 24 hours

§ 245D.06, subd. 1 requires a report to the legal representative or emergency contact and the case manager within 24 hours of an incident or its discovery. Fix: define "incident" in your policy exactly as the statute does, and log each notification with who, when, and how. The 245D incident reporting guide has the full chain.

8. Emergency use of manual restraint reports late or missing

The June 2024 order cites § 245D.061, subd. 5 to 8 because daily log notes documented manual restraints that were never reported. Fix: train staff that any manual hold in an emergency is an EUMR, and start the 3-calendar-day, 5-working-day, 5-working-day, and 5-working-day sequence from the event.

9. Prohibited procedures and rights restrictions

Both 2024 orders cite § 245D.06, subd. 5 or § 245D.04, subd. 3 for withholding goods or services as a behavioral consequence. Fix: any restriction of a protection-related right must be documented as necessary for health or safety and approved in writing, and staff must be retrained on prohibited procedures when a note shows one.

10. Medication administration records

§ 245D.05, subd. 1a requires setup dates, medication name, dose, times, and route; subd. 2 requires written authorization and entries for each administration, refusal, error, or change; subd. 4 requires a quarterly review of medication administration records. The August 2024 order cites all three. Fix: use a MAR that cannot be closed without setup fields, and calendar the quarterly review.

11. Abuse prevention plans

§ 245D.071, subd. 2 requires an individual abuse prevention plan prior to or upon service initiation under § 245A.65, subd. 2, and § 245A.65 requires orientation to the program abuse prevention plan within 24 hours of admission. The August 2024 order cites the 24-hour orientation. Fix: put the plan and the orientation acknowledgment in the admission packet with dated signatures.

12. Rights notification and policies not given

§ 245D.04, subd. 1 requires written notice of service recipient rights within 5 working days of service initiation and annually, with documented receipt. § 245D.10, subd. 4 requires copies of the policies affecting those rights within the same 5 working days. "Probably sent by email" was not accepted in the August 2024 order. Fix: keep a signed acknowledgment for each document in the service recipient record.

13. Funds and property records

§ 245D.06, subd. 4 requires written authorization from the person, legal representative, and case manager within 5 working days before staff assist with funds, and records of receipts and disbursements. Fix: use a ledger with a signature on each entry and reconcile it monthly.

14. Emergency plans and quarterly drills

For community residential settings, § 245D.22, subd. 5 requires a written emergency plan and procedures for conducting quarterly drills with the date of each drill recorded. Fix: schedule the drills in advance and keep the log at the site.

15. Service termination notice

§ 245D.10, subd. 3a requires written notice at least 60 days before terminating intensive support services and 30 days before terminating other licensed services, stating the reason, the efforts made to prevent termination, and appeal rights under § 256.045. Fix: use a template that cannot be issued without those elements, and consult the support team before the notice goes out.

Audit tip: most items above are date failures, not judgment failures. Before a review, pull every client's initiation date, every staff person's hire date, and every incident date, then check the deadline that hangs off each one.

What a correction order contains and how to respond

§ 245A.06, subd. 1 requires a correction order to state the conditions that constitute a violation of law or rule, the specific law or rule violated, and the time allowed to correct each violation. Corrective action often includes submitting proof, such as retraining records or a corrected medication review, to the licensor within 10 to 30 days. For HCBS programs, subd. 1a requires site-specific orders for multi-site license holders and a warning before a conditional license is issued.

Reconsideration under subd. 2 must be requested in writing within 20 calendar days of receiving the order. The request must identify each violation challenged, explain why it is in error, and include documentation. It does not stay the order, so correction should continue while the request is pending. If DHS denies reconsideration, 245D programs are offered mediation at the license holder's expense. Under subd. 3, failure to correct allows DHS to impose fines and other sanctions under § 245A.07.

Conditional licenses and fines under § 245A.07

A conditional license adds terms for a stated period. The two 2024 orders were issued to license holders already on conditional licenses, and one cites failure to follow a term requiring notice to the licensor of new hires. Reconsideration of a conditional license under § 245A.06, subd. 4 must be requested within 10 calendar days, and a timely request does stay the conditional license.

§ 245A.07, subd. 3 sets the fine schedule: $1,000 for each determination of maltreatment of a child or a vulnerable adult, $5,000 if it meets the definition of serious maltreatment, $200 for each violation of a rule governing health, safety, or supervision, and $100 for each other violation. A fine is appealed within 10 calendar days of notice, and failure to pay allows a second fine or suspension. Suspension and revocation are appealed within 10 calendar days; a temporary immediate suspension under subd. 2, for imminent risk of harm, must be appealed within 5 calendar days.

How Trustora helps

Trustora's 245D module is built around the dates in this list. The service initiation date starts the 15-day, 45-days-of-service or 60-day, 10-working-day, 20-working-day, and progress review clocks; the hire date starts the 72-hour, 60-day, and annual training clocks; and an incident entry starts the 24-hour and emergency manual restraint sequence. Gap-day alerts fire before each step is late, and signed acknowledgments are stored in the service recipient record.

When a licensor asks for a sample, the one-click DHS audit binder produces client and staff records for the period requested. See the platform overview for the 245D compliance engine.