United States District Court, M.D. Pennsylvania
MATTHEW W. BRANN, District Judge.
Before the Court is the Report and Recommendation of Magistrate Judge Gerald B. Cohn recommending that the Court affirm the Social Security Commissioner's decision denying Plaintiff disability insurance benefits and Plaintiff's objections thereto. ECF Nos. 20, 21. After a thorough examination of the record, and for the reasons that follow, the Administrative Law Judge ("ALJ") did not base his decision on substantial evidence. Therefore, the case is remanded to the Commissioner for further proceedings.
I. PROCEDURAL HISTORY
On February 24, 2011, Plaintiff, ("Harper"), filed an application for Disability Insurance Benefits ("DIB") and Social Security Income ("SSI") alleging disability, beginning June 2010 as a result of mental impairments. Tr. 160-69. Benefits were initially denied. Harper then requested and was granted an administrative hearing. On May 25, 2012, Harper appeared before the ALJ where Harper, who was represented by counsel, his wife, and a vocational expert testified. Tr. 103-34. The ALJ, using the sequential evaluation process for disability, issued an unfavorable decision. Tr. 21-37. On September 9, 2013, the Appeals Council denied Harper's request for review making the ALJ's findings the final decision of the Commissioner. Tr. 1-7, 19-20.
On November 18, 2013, Harper appealed the final decision to this Court and the case was referred to Magistrate Judge Cohn. The Magistrate Judge issued his Report and Recommendations on February 12, 2015 and concluded that the ALJ's decision was supported by substantial evidence. ECF No. 20. He recommended that the Court deny Harper's appeal and affirm the decision of the Commission. ECF No. 20. Harper filed objections on March 2, 2015. ECF No. 21.
II. FACTUAL BACKGROUND
Harper attended the Wyoming Valley Alcohol and Drug (WVADS) Services Inc. from September 2009 to June 2010. Tr. 342. On June 9, 2010, Harper presented to the emergency room at Wyoming Valley Healthcare complaining of suicidal thoughts, with a plan to jump off a bridge and thoughts of killing his wife and her alleged lover. Tr. 299. At the time of his admission, he was alert and oriented, his memory was "normal", and his affect was "flat." Tr. 300-01. Harper was then given a psychiatric evaluation. Tr. 304. His mental status exam indicated that he was alert, oriented, neat with good hygiene and had appropriate psychomotor activity. Tr. 305. His mood was depressed and anxious, he denied hallucinations and delusions, his memory and recall were fair, and his insight and judgment were poor. Tr. 307.
Harper was diagnosed with bipolar disorder and was recommended for transfer to a psychiatric hospital. Tr. 309. Later that day, Harper was transferred to First Hospital Wyoming Valley. Id. On admission, he was alert and oriented with depressed mood, impaired insight/judgment, and poor impulse control. Tr. 311.
On November 4, 2010, Harper was transferred to Clarks Summit State Hospital ("Clarks Summit") for depression. Tr. 324. Upon his admission at this facility, it was recorded that he no longer had suicidal or homicidal ideation. Tr. 324. Also, he had no recent history of assaultive or aggressive behavior, but was described as becoming agitated at times. Tr. 324. His mental status examination indicated that he was mostly cooperative but was "somewhat slightly guarded with limited eye contact." Tr. 325. His thought content "revealed no overt delusions" and "there were no reported hallucination." Tr. 325. His intellectual level appeared to be low average, his insight and judgment were limited, and his impulse control seemed fair. Tr. 325. He was assigned a GAF score of 40. Tr. 328.
Doctors found that Harper's condition was improving and he was compliant with his medication and treatment. Tr. 339. Certain stressors, for example, his wife's incarceration, had been alleviated since her release from custody. Tr. 339. Harper was discharged on January 19, 2011 with a diagnosis of "Major Depression, Single Episode" and given a GAF score of 70. Tr. 328. At the time, he denied suicidal or homicidal ideation and reported no hallucinations. Tr. 327.
On February 18, 2011, Harper was evaluated at the Community Counseling Service ("Community Counseling"). Tr. 372. He reported that he had been released from Clarks Summit after being treated for depression. Tr. 372. He stated that he was hearing voices, but not hearing them at the present time, and denied suicidal or homicidal ideation. Tr. 372. On examination, his mood and affect were "bright", his behavior was "controlled", his appearance was" neat", his insight was "fair" and his judgment was "questionable". Tr. 372. He was diagnosed with schizoaffective disorder and borderline mental retardation. Tr. 372. A physician note from the same date, however, indicated that Harper denied experiencing any delusions and hallucinations. Tr. 378. He was prescribed Celexa, Seroquel, Cogentin, and Lithium. Tr. 373.
On February 24, 2011, Harper applied for DIB and SSI. Tr. 160-69. He submitted a Function Report where he reported problems sleeping, dressing, bathing, caring for his hair, and shaving. Tr. 277. He explained that he "sometimes needs to be told to shower" and that his wife has to shave him because he cannot concentrate. Tr. 277. He reported that he needed reminders from his wife to take his medication and to take care of himself. Tr. 277. He also claimed that he went outside "very rarely" because he is "paranoid, confused, anxious, and cannot be around a lot of people." Tr. 279. He reported "seeing things that aren't there, and problems with concentration, memory, understanding, distraction and confusion." Tr. 281. He also reported having problems handling stress and changes in routine. Tr. 282. Harper's wife also submitted a Function Report, which indicated the same limitations as Harper's Function Report. Tr. 267-74. She explained that she "noticed a substantial change in his mood and that he complained of auditory and visual hallucinations." Tr. 274.
On March 22, 2011, Harper reported increased hostility and hallucinations to doctors at the Community Counseling. Tr. 379. The doctor's notes indicated that Harper's hallucinations were not "24/7 but seemed more frequent.'" Tr. 379. The notes revealed that Harper's schizoaffective disorder was worsening and his Seroquel dosage was increased. Tr. 379. Doctors also encouraged compliance with his medication. Tr. 379.
On Harper's subsequent visit to Community Counseling on April 15, 2011, he again reported experiencing occasional non-commanding auditory hallucinations. Tr 380. Harper was compliant with his medication and he reported "no anxiety" but "poor concentration." Tr. 380. He had mild psychomotor retardation, blunted and inattentive affect, and a neutral mood. Tr. 380.
On May 13, 2011, at his next Community Counseling appointment, Harper reported irritability, occasional visual hallucinations such as seeing shadow and lights, but no auditory hallucination. Tr. 381. He was alert and oriented, clean, "argumentative but fairly cooperative, " had blunted affect, irritable mood, and poor insight/judgment. Tr. 381. Harper told his physicians that he was not complaint with his medication and had been missing doses. Tr. 381.
On May 26, 2011, Harper had a consultative exam with a state agency psychologist, Dr. Sara Cornell, Psy. D. Tr. 391. He reported that his depression began in 2008 and his symptoms included sadness, crying, fatigue, and social isolation. Tr. 389. He stated that he had no friends, experienced irritability and preferred to stay away from public places and people due to this irritability and mood swings. Tr. 389. Harper reported experiencing hallucinations, voices telling him what to do and seeing things, like mice or shapeless objects running across the floor of his house. Tr.390. Dr. Cornell noted that Harper exhibited "no tics, repetitive, stereotypical or odd movements, made fair eye contact, and had fair social skills." Tr. 391. Harper had difficulty providing examples ...