CWA 216813 (05/09/2025)
IRIS disenrollment for cluttered house, health and safety

Preliminary Recitals

Pursuant to a petition filed on January 28, 2025, under Wis. Admin. Code § HA 3.03, to review a decision by the Bureau of Long-Term Support regarding IRIS / Medical Assistance (MA), a hearing was held on March 12, 2025, by telephone.

The issue for determination is whether the agency properly disenrolled Petitioner from the IRIS program due to health and safety concerns.

There appeared at that time the following persons:

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Sue Rothe, First Person Care Consultants
Bureau of Long-Term Support
PO Box 7851
Madison, WI 53707-7851

ADMINISTRATIVE LAW JUDGE:
Teresa A. Perez
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Milwaukee County who is enrolled in the IRIS Program. First Person Care Consultants is his IRIS Consultant Agency (“ICA” / “the agency”).
2. Petitioner resides with his spouse in a house in the community.
3. Petitioner’s medical diagnoses include but are not limited to: chronic obstructive pulmonary disease (COPD), diabetes, liver disease, cardiomyopathy, arthritis, chronic low back pain, spinal stenosis, anxiety, and depression.
4. Petitioner requires assistance with bathing, dressing, ambulating in his home, toileting, and transferring. He also requires assistance with meal preparation, medication administration / management, and laundry / chores.
5. Petitioner falls approximately twice a month due to numbness in his legs.
6. Petitioner’s house is crowded by his possessions to the extent that there is insufficient room to move safely and freely. Although Petitioner and his spouse endeavor to maintain a clean home, it is impossible to thoroughly clean because of the volume of clutter.
7. In February 2023 and January 2024, the agency issued, and Petitioner signed, risk agreements related to the obstructions caused by the clutter present in his home. Petitioner voiced willingness to accept assistance during conversations with agency prior to signing the risk agreements. The agency advised Petitioner of the urgency of decluttering his home each time. The agency also provided Petitioner with the names of organizations and businesses that could assist him and his wife with the process of decluttering his home.
8. The agency issued a third risk agreement to Petitioner in October 2024 because his home remained cluttered and because he had not retained assistance to declutter. At this time, the agency advised Petitioner that if he did not make progress in decluttering his home, he could be involuntarily disenrolled from IRIS. In addition, the agency contacted businesses on Petitioner’s behalf to obtain estimates on the cost of decluttering and cleaning his home. One of the businesses declined the job after visiting Petitioner’s home. One of the businesses expressed willingness to do the work but only if Petitioner first hired an exterminator. Petitioner declined to do so.
9. Via notice dated January 16, 2025, the agency informed Petitioner that he would be disenrolled from IRIS due to health and safety concerns; specifically, concerns regarding severe clutter in his home and smoking in his home despite the presence of oxygen equipment.

Discussion

The IRIS program is a Medical Assistance (MA) home and community-based long term care waiver program authorized under §1915(c) of the Social Security Act. See also, 42 C.F.R. §441.300, et. seq. IRIS is an alternative to Family Care, Partnership, and PACE—all of which are managed care programs. The IRIS program, in contrast, is designed to allow participants to direct their own care and to hire and direct their own workers.

The waiver approved by the Centers for Medicare and Medicaid Services (CMS) which proves the IRIS program’s authority is available at https://www.dhs.wisconsin.gov/iris/hcbw.pdf. State policies governing administration of the IRIS program are included in the IRIS Policy Manual (available at http://www.dhs.wisconsin.gov/publications/P0/P00708.pdf) and IRIS Work Instructions (available at http://www.dhs.wisconsin.gov/publications/P0/P00708a.pdf).

The waiver requires IRIS Consultant Agencies (“ICAs”) to monitor health and safety as part of service planning, to try to eliminate health and safety concerns, when they arise, in partnership with the participant, and to disenroll participants when health and safety concerns remain despite remediation efforts. Specifically, the waiver provides:

Regular meetings … provide the opportunity for the [IRIS Consultant] to monitor the participant’s back-up plan and health and safety. ICs may mitigate risk of threats to health and safety by connecting participants with resources for addressing their own health and safety risks. … If the participant refuses, or is unable, to address his or her own health and safety, or refuses the assistance of the IRIS Consultant, the IRIS Consultant has the responsibility to recommend involuntary disenrollment.

Application for a 1915(c)Home and Community Based Services Waiver WI.0485.R01.00, Appendix D-2a.; see also Appendix E-1m. and Appendix D-1e.

Consistent with the above-quoted waiver language, IRIS program policy issued by the Department of Health Services includes the following directions regarding the involuntary disenrollment of IRIS participants:

2. Program Requested Disenrollment

a. Disenrollment Process

… ICAs are responsible for recommending program requested disenrollments when a reason for disenrollment is identified and applicable remediation attempts have not resolved the issue … The reasons for program requested disenrollment, their definitions, and any required remediation include the following:

iii. Health and Safety: The ICA selects this reason when they are unable to ensure the health and safety of the participant.

1. 1. Remediation/Documentation Required: The ICA must provide documentation of efforts to assist the participant in resolving the health and safety issue, including any applicable attempts at risk mitigation.

Program Enrollment Addendum to IRIS Policy Manual and Work Instructions (available at https://www.dhs.wisconsin.gov/publications/p03547.pdf).

It is thus clear that an IRIS participant may be disenrolled from the program based on health and safety risks but that the ICA has an obligation to make efforts to remediate health and safety risks before disenrolling a participant. In this case, the agency produced photographs of Petitioner’s home taken in September 2024 that substantiate the agency’s contention that Petitioner’s possessions do not allow sufficient space to move freely and safely. At hearing, Petitioner’s spouse acknowledged that there is too much clutter, that there are bags stacked up in places and that they are unstable, and that she understood the agency’s statements regarding insufficient travel paths. She also testified that she had in the week prior to the hearing cleared out quite a bit of clutter from the kitchen.

Petitioner testified that their home is not dirty, that most possessions are in plastic bins and neatly stacked, and that some of the bags present are his recently deceased sister’s belongings which he is not intending to keep forever. He also testified that he and his spouse can’t keep things as organized as they would like due to their respective health conditions and that he would like help. However, the evidence in the record established that he has been offered assistance and has declined that assistance for one reason or another.

Petitioner asked that I give him an opportunity to submit photographs of their house to rebut the agency’s evidence. I did so and reviewed the photographs closely. Those photographs show that his spouse did remove some clutter from the kitchen but also show that the physical environment in which he lives continues to present health and safety risks due to the remaining clutter.

I am going to uphold the agency’s disenrollment because a preponderance of the evidence established that the agency has identified a valid health and safety concern and that the agency has made good faith efforts to assist Petitioner in remediating that concern over the past two years.

I note that Petitioner stated that he is depressed and sick. I do not doubt that Petitioner feels poorly that he is not up to the task of independently decluttering his home, and that he has sincere emotional attachments to his possessions which make that task even more daunting. Petitioner will be referred to the Aging and Disability Resource Center upon disenrollment from IRIS and will likely be eligible to enroll in Family Care, a managed long term care program that can provide a level of assistance and oversight that is not available through a self-directed program.

Conclusions of Law

The agency properly seeks to disenroll Petitioner from IRIS due to health and safety concerns that remain present in his home despite the agency’s efforts to address those concerns.

THEREFORE, it is

Ordered

Petitioner’s appeal is dismissed.

[Request for a rehearing and appeal to court instructions omitted.]