United States District Court, Western District of Pennsylvania
NORA BARRY FISCHER, DISTRICT JUDGE.
Maria Soto (“Plaintiff”), brings this action pursuant to 42 U.S.C. § 405(g), seeking review of the final determination of the Commissioner of Social Security (“Commissioner” or “Defendant”) denying her applications for disability insurance benefits (“DIB”) and supplemental security income (“SSI”) under Titles II and XVI of the Social Security Act, 42 U.S.C. § 401, et seq. and § 1381 et seq. This matter comes before the Court on cross-motions for summary judgment pursuant to Rule 56(c) of the Federal Rules of Civil Procedure. (ECF. Nos. 9, 11). The record has been developed at the administrative level. (ECF No. 7). For the following reasons, Plaintiff’s Motion for Summary Judgment (ECF No. 9) is granted, in part, and denied, in part, and Defendant’s Motion for Summary Judgment (ECF No. 11) is denied.
II. PROCEDURAL HISTORY
Plaintiff filed her applications on June 30, 2010 and January 18, 2011, claiming disability since April 15, 2010 due to back problems, thyroidism, high blood pressure, and high cholesterol. (R. at 168-177, 191). Her applications were denied (R. at 67-76), and she requested a hearing before an administrative law judge (“ALJ”). (R. at 77-78). A hearing was held on August 17, 2012, during which Plaintiff appeared and testified, and George Starosta, an impartial vocational expert, also appeared and testified. (R. at 29-52). On August 28, 2012, the ALJ issued a written decision denying benefits. (R. at 16-25). Plaintiff’s request for review by the Appeals Council was denied (R. at 1-8), rendering the Commissioner’s decision final under 42 U.S.C. § 405(g). She filed her complaint challenging the ALJ’s decision on January 21, 2014 (ECF No. 3), and the parties subsequently filed cross-motions for summary judgment. (ECF Nos. 9, 11). Accordingly, the matter has been fully briefed and is ripe for disposition.
A. General Background
Plaintiff was forty-five years old on the alleged disability onset date. (R. a 24). She was a high school graduate, and had past relevant work experience as a cashier and kitchen helper at a restaurant at Disney World. (R. at 24, 191). On February 18, 2011, Plaintiff completed a Function Report on a form supplied by the Commissioner. (R. at 198-205). Plaintiff reported that she was independent in her personal care, able to prepare meals, and able to perform household chores except when experiencing back pain. (R. at 198-200). Plaintiff further reported that she watched television, visited with others in her home once a week, regularly attended church and doctor’s appointments, and shopped for groceries. (R. at 202). Plaintiff described her ability to follow instructions and get along with authority figures as “very well, ” and she was able to handle stress “with God[’s] help.” (R. at 203-204).
On February 15, 2011, Plaintiff sought mental health treatment at Safe Harbor Behavioral Health. (R. at 308). She reported suffering from depression for a “few weeks” due to her physical health problems. (R. at 308). She complained of trouble sleeping, self-isolation, frequent crying and racing thoughts. (R. at 308). Plaintiff stated that she occasionally heard voices commenting on her mood, but denied having command hallucinations. (R. at 308). Upon mental status examination, Plaintiff was fully oriented, cooperative, and alert, maintained adequate eye contact and displayed adequate hygiene. (R. at 311). Her speech was soft and spontaneous, her affect was appropriate, and her thought processes were organized and relevant. (R. at 311). Plaintiff had some minor memory problems, but she had average intellect, and her insight and judgment were “good.” (R. at 311). Plaintiff was assessed with unspecified episodic mood disorder and assessed with a Global Assessment of Functioning (“GAF”) score of 50. (R. at 312).
Plaintiff returned to Safe Harbor on March 9, 2011 and reported that she had been mildly depressed since April 2010, when she started having back problems and her work hours were reduced. (R. at 302). Plaintiff reported that her hours were reduced following a downturn in the economy, and she was unable financially to remain in Florida. (R. at 303). She stated that she last worked in March 2010 and left Florida to move to Erie. (R. at 303). Plaintiff reported that she had never been hospitalized, seen a psychiatrist or therapist, or been on psychotropic medication. (R. at 302). She complained of insomnia, frequent crying, and hearing her own voice commenting on her mood, but denied any command hallucinations. (R. at 302). She stated that her energy level was “pretty good.” (R. at 302). She reported that she was able to keep up with cleaning, attend church, grocery shop, and spend time with friends. (R. at 302). Plaintiff indicated that she always had company at her house and did not like to be alone. (R. at 302).
During a mental status examination, Plaintiff was alert and fully oriented and cooperative. (R. at 303). She had good grooming and hygiene. (R. at 303). She was pleasant and smiled throughout the session, her speech was spontaneous, clear and coherent, and her thought processes were coherent and appropriate. (R. at 303). Her mood and affect were normal. (R. at 303). Plaintiff’s knowledge, intelligence, and vocabulary appeared to be average. (R. at 303). She had good concentration and was not easily distracted. (R. at 303). Her insight, judgment, and impulse control were good. (R. at 303). Plaintiff was assessed with major depressive disorder, single episode, mild, and was assessed with a GAF score of 55. (R. at 303-304). Plaintiff’s treatment plan included medication and therapy, and she was prescribed Prozacfor depression and Remeron for insomnia. (R. at 303). She began therapy the next day. (R. at 301).
On April 19, 2011, Plaintiff reported that her medications were helpful, her mood was “pretty good, ” she was no longer crying all the time, and she felt less depressed and anxious. (R. at 270). She further reported that she was more active and continued to be sociable. (R. at 270). Plaintiff indicated that she was sleeping better at night, but felt the Remeron was too strong. (R. at 270). On examination, Plaintiff was alert, oriented, displayed good grooming and hygiene, and maintained good eye contact. (R. at 270). Her speech was clear and coherent, her mood and affect were normal, her stream of thought was well-organized and goal oriented, and her impulse control and judgment were good. (R. at 270). She was assessed with a GAF score of 57. (R. at 271). Vistaril was added to her medication regimen, and it was suggested she take half her Remeron dosage. (R. at 271).
Plaintiff returned to Safe Harbor on May 31, 2011 and reported that she did not think her mood was any better, and she suffered from depression “off and on” due to back pain. (R. at 268). Plaintiff further reported that her anxiety symptoms came and went. (R. at 268). She indicated that her sleep varied, mainly due to pain, but she was able clean, take care of her home, and perform light gardening. (R. at 268). Once again, Plaintiff reported to be alert and oriented, her speech was clear and coherent, and her mood and affect were normal. (R. at 268). Her stream of thought was well-organized and goal oriented, and her insight, impulse control and ...