United States District Court, E.D. Pennsylvania
commenced the within action after being denied Supplemental
Social Security Income Benefits and Disability Insurance
Benefits. Upon review by United States Magistrate Judge Jacob
P. Hart, a Report and Recommendation (R&R) was issued
affirming the Administrative Law Judge's (ALJ) denial of
said benefits. Plaintiff has filed objections to the R&R,
which are now before this Court for review. For the reasons
set forth below, Plaintiffs objections shall be granted and
the matter shall be remanded to the Commission of the Social
Security Administration for further proceedings.
September 9, 2013, Plaintiff submitted applications for
Disability Insurance Benefits and for Supplemental Security
Income, in which she alleged disability beginning July 4,
2013. (Admin. R. 220, 227.) Said applications were initially
denied on February 19, 2014. (Admin. R. 104, 109.) Plaintiff
filed a written request for a hearing on the decision on
April 17, 2014, which was held via video on September 23,
2014 and presided over by ALJ Lawrence J. Neary. (Admin. R.
113.) On December 2, 2014, ALJ Neary issued an unfavorable
decision regarding Plaintiffs claims. (Admin. R. 19.) On
January 28, 2015, Plaintiff filed a Request for Review of the
ALJ's determination, which was denied by the Appeals
Council on June 21, 2016. (Admin. R. 17.) As such, Plaintiff
commenced the above-captioned action on December 12, 2016.
Upon completion of briefing, this matter was referred to
United States Magistrate Judge Jacob P. Hart for preparation
of a Report and Recommendation. Judge Hart ultimately
determined that Plaintiffs request for relief should be
denied. Plaintiff filed timely objections to Judge Hart's
R&R, which are now before this Court for consideration.
the date of her administrative hearing on September 23, 2014,
Plaintiff was 50 years old. (Admin. R. 49.) According to
Plaintiffs testimony, she had not engaged in any work for pay
or profit since July 4, 2013. (Admin. R. 51.) Prior to that
time, Plaintiff was employed as a part time taxi dispatcher,
a fast food worker at McDonald's, and a pie line worker
at Sweet Street. (Admin. R. 51.)
22, 2012, Plaintiff was admitted to Reading Hospital and
Medical Center, and was diagnosed with dental abscess and
dental pain. (Admin. R. 312.) Plaintiff was prescribed
several medications for the pain and discharged the same day.
(Admin. R. 312.) Prior to the discharge, Plaintiff indicated
that she was not "under the influence of drugs/alcohol,
" that she had "no history of substance abuse,
" and that she had "no unresolved social
issues." (Admin. R. 311.) Plaintiff was advised to
"[f]ollow up with Primary Care Physician as needed,
Follow up with Specialist within 1 week." (Admin. R.
five months later-November 16, 2012- Plaintiff returned to
the hospital complaining of chest pain. (Admin. R. 314.)
Plaintiff was diagnosed with acute bronchitis, acute
sinusitis, and asthma. (Admin. R. 320.) Prior to discharge,
Plaintiff again indicated that she was not "under the
influence of drugs/alcohol, " that she had "no
history of substance abuse[, ]" and that she had
"no unresolved social issues." (Admin. R. 317.)
Upon discharge, Plaintiff was prescribed several medications,
was given the number for the Berks Community Health Center
with instructions to schedule an appointment, and was told to
come back to the emergency room if her condition worsened.
(Admin. R. 321.)
September 6, 2012 to August 1, 2013, Plaintiff received
treatment at the Berks Community Health Center, where she was
attended to by Dr. Ajay Jani and Nurse Practitioner Cindy
Schmeltz. (Admin. R. 412, 414, 422.) On March 19, 2013,
Plaintiff called the Berks Community Health Center sick line
and talked to Veronica Diaz. (Admin. R. 414.) Plaintiff
stated that she had "been experiencing left sided
numbness to arm extended down towards leg, " that the
pain had been going on for days, and that one side was weaker
than the other. (Admin. R. 414.) On March 26, 2013, Plaintiff
again met with Nurse Schmeltz (Admin. R. 415.) During this
visit, Plaintiff complained of- among other things-sharp pain
on her left side, which she rated as "seven" on a
scale of one to ten, "one" being the least painful.
(Admin. R. 415.) Nurse Schmeltz noted that the patient
occasionally used marijuana-a potential risk factor. (Admin.
R. 417.) On April 4, 2013, an x-ray report from St.
Joseph's Medical Center indicated that Plaintiff suffered
from "cervical spine degenerative disease C5-C6"
and that "there is encroachment upon neural foramina
bilaterally." (Admin. R. 422.)
the course of her treatment at Berks, Nurse Schmeltz
indicated that Plaintiff "suffered a TIA and has some
difficulties in her speech, thinking, motor control and
gait." (Admin. R. 395.) Nurse Schmeltz also stated that
"it is recommended at this time, that she not be working
to allow her to go to the necessary therapies for her to
regain function." (Admin. R. 395.) On her Employability
Assessment Form, Nurse Schmeltz indicated that Plaintiff was
temporarily disabled and that the temporary disability began
August 1, 2013 and was expected to last until December 1,
2014. (Admin. R. 404.)
5, 2013, Plaintiff was admitted to Reading Hospital and was
diagnosed with a generalized seizure, as well as numbness and
tingling. (Admin. R. 441.) On July 16, 2013, Plaintiff again
met with Nurse Schmeltz. (Admin. R. 431.) Plaintiff informed
Schmeltz that "she rubbed cocaine on her tooth times 2
for a toothache [but] was clean for 16 years prior to this
use." (Admin. R. 431.) During the examination, Nurse
Schmeltz noted that Plaintiff had "expressive
aphasia" and "[generalized weakness." (Admin.
R. 432, 440.)
October 3, 2013, Plaintiff went to Reading Hospital
complaining of a possible stroke. (Admin. R. 451.) Upon
examination, the following issues were noted: slurred speech;
transient ischemic attack (TIA); cocaine abuse; generalized
seizure; cerebral infraction without residual deficits;
debility; and, marijuana use. (Admin. R. 451.) Dr. Ray A.
Morganti noted in Plaintiffs record that she was "unable
to raise left LE above stretcher more than a few inches due
to pain in anterior right thigh that patient reports is sore
from falling." (Admin. R. 458.)
January 11, 2014, Plaintiff met with Dr. Celestine Nnaeto.
(Admin. R. 554.) The doctor reported that she had slurred
speech and that her "short term memory seemed
impaired." (Admin. R. 557.) On April 29, 2014, providers
with the FamiliCare Counseling Center reported that Plaintiff
was molested as a child. (Admin. R. 575.) They further
reported that although she had past suicidal ideations, she
has no current suicidal thoughts. (Admin. R. 575.) They also
reported that Plaintiff had past legal charges for
"possession of cocaine, conspiracy, marijuana, school
fines, PV [and] simple assault." (Admin. R. 576.) At
Plaintiffs July 12, 2014 visit to FamiliCare, Plaintiff was
"stressed" and "appeared tearful, depressed,
lack of motivation, fearful and passive thoughts of
self-harm, self-defeat during the session. Thoughts negative,
circumstantial. Sleep poor, disrupted, passive SI with no
specific plan, visual/auditory hallucination, panic
attacks." (Admin. R. 584.) The therapist further noted
that Plaintiff had been "scratching her skin until it is
raw, reports lack of motivation for self care, low self
esteem, inability to leave house due to panic reaction when
exposed to outside stimulus. Will have racing heartbeat and
shortness of breath. Intensity is 10, happening through the
day, most of the waking hours." (Admin. R. 585.) At that
time, she was diagnosed (in part) with "major depression
single ep[.]" (Admin. R. 586.)
28, 2014, Plaintiff met with Dr. James A. Coffey, a vascular
specialist. (Admin. R. 797.) During that visit, Plaintiff
admitted to "depression[, ] syncopal episodes[, ] and
use of tobacco as well as THC." (Admin. R. 797.) The
record also showed that Plaintiff last used marijuana in
April 2014 and after being clean for 16 years, suffered a
relapse of crack cocaine in March 2014. (Admin. R. 799.)
Plaintiff was given prescription medications and discharged
with instructions to follow up. (Admin. R. 803.)
August 11, 2014, Plaintiff met with Neurologist Lawrence A.
Brzozowski. (Admin. R. 779.) Dr. Brzozowski noted that
Plaintiff had a history of polysubstance abuse, prior cocaine
use, and recent marijuana and tobacco abuse. (Admin. R. 780.)
Dr. Brzozowski determined that Plaintiff had "a postural
tremor bilaterally, " further noting that the only
"muscles that have 5/5 power are her right knee extensor
and right foot dorsiflexor. Right sided muscles are generally
4 left sided muscles are 4 to 4-/5 power." (Admin. R.
783.) Dr. Brzozowski also noted that that the "[p]atient
stands well by herself. She walks with a quad cane in her
right hand with her left leg abducted and a left leg limp and
is unsteady." (Admin. R. 783.) Finally, on October 14,
2014, Plaintiff was admitted at Digestive Disease Associates,
where she was treated for chronic constipation, generalized
abdominal pain, bloating, and dysphagia. (Admin. R. 813.)
Standards of Review
to an R&R issued by a magistrate judge are entitled to
de novo review by the district court. 28 U.S.C.
§ 636(b)(1)(C). However, review of a final decision of
the Commissioner of Social Security is deferential and is
limited to determining whether the Commissioner's
decision is supported by substantial evidence. 42 U.S.C.
§§ 405(g), 1383(c)(3); Jenkins v. Comm 'r
of Soc. Sec, 192 Fed.Appx. 113, 114 (3d Cir. 2006).
Substantial evidence is difficult to precisely define; it
'"does not mean a large or considerable amount of
evidence, but rather such relevant evidence as a reasonable
mind might accept as adequate to support a
conclusion.'" Hartranft v. Apfel, 181 F.3d
358, 360 (3d Cir. 1999) (quoting Pierce v.
Underwood, 487 U.S. 552 (1988)). In terms of the
traditional burden of proof standards, substantial evidence
is "more than a mere scintilla but may be somewhat less
than a preponderance of the evidence." Ginsburg v.
Richardson, 436 F.2d 1146, 1148 (3d Cir. 1971). However,
In making this determination ... the court must consider
"the evidentiary record as a whole, not just the
evidence that is consistent with the agency's
finding." Monsour, 806 F.2d at 1190. "A
single piece of evidence will not satisfy the substantiality
test if the Secretary ignores, or fails to resolve, a
conflict created by countervailing evidence. Nor is evidence
substantial if it is overwhelmed by other evidence ... or if
it really constitutes not evidence but mere conclusion."
Kent v. Schweiker, 710 F.2d 110, 114 (3d Cir. 1983).
McClease v. Comm 'r of Soc. Sec, Civ. No.
08-1673, 2009 U.S. Dist. LEXIS 101190, at *8 (E.D. Pa. Oct.