CWA 219663 (10/13/2025)
IRIS participant disenrolled for health and safety after 25 critical incidents in 9 months

Preliminary Recitals

Pursuant to a petition filed August 20, 2025, under Wis. Admin. Code, §HA 3.03, to review a decision by the Bureau of Long-Term Support to discontinue the Include, Respect, I Self-Direct program (IRIS), a hearing was held on October 8, 2025, by telephone.

The issue for determination is whether the agency correctly determined that health and safety concerns result in IRIS disenrollment.

PARTIES IN INTEREST:

Petitioner:
—

Respondent:
Department of Health Services
1 West Wilson Street, Room 651
Madison, WI 53703
By: Angela Sutherland
TMG
2424 Rimrock Rd., Suite 230
Fitchburg, WI 53713

ADMINISTRATIVE LAW JUDGE:
Brian C. Schneider
Division of Hearings and Appeals

Findings of Fact

1. Petitioner is a resident of Rusk County. She recently moved from Dunn County.
2. Petitioner has been eligible for IRIS since 2014. TMG is her consulting agency (ICA).
3. Petitioner meets both the physical disability and persistent mental illness target groups for IRIS. She requires hands-on care for bathing, dressing, and transfers, and supervision for mobility and toileting. She requires hands-on assistance with meal preparation, medication management, laundry/chores, and transportation. She gets assistance 54 hours per week, broken up between supportive home care and self-directed personal care.
4. In recent years petitioner has had an increase in critical incidents, no fewer than five per year beginning in 2021. However, in the first nine months of 2025 she has had 25 critical incidents.
5. Throughout 2025 petitioner has had ongoing difficulty finding and keeping caregivers. A live-in caregiver moved out in July, resulting in petitioner being hospitalized because she had no support. She lost all back-up support workers, and on August 4, 2025, she reported that she was being evicted from her apartment; at that point she had neither natural nor back-up supports.
6. TMG put together three risk agreements for petitioner in 2025, on April 15, May 13, and later on September 23. In the meantime she also lost her mental health provider, and by September she was looking to move again (which she did just before the hearing).
7. Soon after petitioner reported the eviction, TMG, by a notice dated August 7, 2025, informed petitioner that she was being disenrolled effective August 22, 2025 because the agency could not ensure her health and safety. Eligibility was maintained pending this decision.

Discussion

The IRIS program was developed pursuant to a Medical Assistance waiver obtained by the State of Wisconsin, pursuant to section 6087 of the Deficit Reduction Act of 2005 (DRA), and section 1915(j) of the Social Security Act. It is a self-directed personal care program. IRIS policies are found online at http://www.dhs.wisconsin.gov/publications/p0/P00708.pdf.

The IRIS Policy and Procedure document describes situations where the agency may involuntarily disenroll a participant. See pages K4 and K5 of the TMG hearing submission. One condition is when the person’s health and/or safety are jeopardized. To utilize this option, the ICA must show efforts to assist the participant in resolving health and safety issues, including risk mitigation.

As noted in the Findings of Fact, petitioner has had 25 critical incidents in just the first nine months of 2025, after having seven, five, five, and five the previous four years. A critical incident is a medical emergency, law enforcement contact, or hospitalization. Petitioner had all three types in 2025. In May, 2025, a police officer told TMG staff that the local department had frequent contact with petitioner and her then-roommate. She had more than one overdose during the year and was hospitalized for more than 24 hours five times. She had trouble finding and retaining staff.

Petitioner explained during the hearing that she now has a stable place to live and is waiting on approval of two new caregivers. The problem is that, given the history this year, there is no guarantee that she will be able to keep the caregivers even if they approved. The absolute chaos in petitioner’s life this year, as documented in TMG records, shows a legitimate concern not only for petitioner’s health and safety, but for her ability to manage her own cares.

I conclude that the agency’s action to disenroll petitioner was reasonable and correct based on Department policy guidelines.

Conclusions of Law

The ICA correctly proposed to disenroll petitioner because of health and safety concerns that arose in 2025.

THEREFORE, it is

Ordered

That the petition for review is hereby dismissed.

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