United States District Court, S.D. New York
REPORT AND RECOMMENDATION
SARAH NETBURN, Magistrate Judge.
TO THE HONORABLE VALERIE E. CAPRONI:
Plaintiff Ephraim Vanterpool, appearing pro se, brings this action pursuant to Section 205(g) of the Social Security Act (the "Act"), 42 U.S.C. § 405(g), seeking judicial review of the final determination of the Commissioner of Social Security (the "Commissioner") denying his application for Supplemental Security Income ("SSI") benefits. The Commissioner moved for judgment on the pleadings pursuant to Rule 12(c) of the Federal Rules of Civil Procedure. Vanterpool did not oppose the motion. Because I conclude that substantial evidence supports the Commissioner's final determination, and because the administrative law judge ("ALJ") did not commit legal error, I recommend that the Commissioner's motion be GRANTED.
On February 12, 2010, Vanterpool submitted an application for SSI benefits. On March 16, 2010, the Social Security Administration (the "SSA") denied this application, and on April 5, 2010, Vanterpool appealed, requesting a hearing before an administrative law judge. Vanterpool appeared with counsel before ALJ Zachary S. Weiss on April 1, 2011. The ALJ issued a decision on May 27, 2011, denying Vanterpool benefits. The Appeals Council denied Vanterpool's request for review of the ALJ's decision on October 19, 2012, thereby rendering the decision of the Commissioner final.
On December 3, 2012, Vanterpool filed this pro se action. On December 7, 2012, the Honorable Paul A. Crotty referred Vanterpool's case to my docket for a report and recommendation. On December 16, 2013, the Commissioner filed a motion for judgment on the pleadings with supporting memorandum of law. On January 17, 2014, the Court issued an Order directing Vanterpool to file a response by January 31, 2014, otherwise the motion would be considered fully briefed. On March 11, 2014, the case was reassigned to the Honorable Valerie E. Caproni. Vanterpool did not file a response to the Commissioner's motion for judgment on the pleadings, and the motion is considered fully briefed.
The following facts are taken from the administrative record.
I. Non-Medical Evidence
Vanterpool is now thirty years old, lives with his parents, and has an eleventh grade education. From the beginning of 2007 until June 2007, Vanterpool worked as a home health aide. In his application for benefits, Vanterpool stated that he needed help or a reminder to brush his teeth, clean, wash his clothes, or clean his room. He needed his mother to remind him to take his medication. Vanterpool prepared his own food weekly, and identified laziness as the reason he sometimes did not prepare his meals. He would sometimes go to the store to buy food. Vanterpool indicated that he could count change but was not able to pay bills, use a checkbook, or handle a savings account. He described himself as having no hobbies or interests, except watching movies or television, which he did every day.
On May 20, 2008, Vanterpool was terminated from the Adult Education and Training Program at Bronx Community College for threatening behavior towards another student. A letter from Bronx Community College indicated that Vanterpool had previously been warned about inappropriate classroom behavior.
II. Medical Evidence
A. North Central Bronx Hospital
Vanterpool was treated at North Central Bronx Hospital from December 16, 2007 to February 4, 2008. He was brought to the emergency room by his mother who believed he was exhibiting increased paranoia and impulsive behavior. Vanterpool had a history of drug abuse but had been sober for six years. He was diagnosed with psychosis, not otherwise specified and given a Global Assessment of Functioning ("GAF") of 35.
Dr. Tasbeeh Fatima noted that Vanterpool was treated in the inpatient unit. He did not exhibit overt psychosis or delusional thinking, and his thoughts were goal oriented. He was, however, mostly isolated in his room. His affect was constricted and his mother reported that he had called her from the facility and had an outburst over the phone. He denied any audiovisual delusions or suicidal or homicidal ideation. His insight and judgment, however, were limited. Vanterpool was started on Seroquel during his stay and was discharged from inpatient care on January 2, 2008 in a stable condition. His GAF upon discharge was 67.
B. Bronx-Lebanon Hospital Center
1. Contemporaneous Medical Records
Vanterpool received treatment at Bronx-Lebanon Hospital Center beginning in March 2008. Vanterpool's March 5, 2008 Comprehensive Treatment Plan indicates a diagnosis of Schizophrenia, Chronic, Paranoid Type. The document also indicates that his GAF at the time was 55, and his best GAF during the past year was 55. The social worker noted that Vanterpool was hospitalized in December 2007 and transitioned to partial hospitalization from January 3, 2008 to February 4, 2008. This is the only evidence of hospitalization in the record. Vanterpool met with his treating physician, Dr. Harneja, and a licensed clinical social worker approximately once a month. His treatment at Bronx-Lebanon Hospital Center continued from 2008 to 2010, with the last treatment record dated October 14, 2010.
Between March 5, 2008 and October 3, 2009, the alleged onset date of Vanterpool's disability, he maintained regular appointments with both his treating physician and his social worker, though he missed appointments in August 2009 and September 2009. Vanterpool's GAF during this time ranged from 55 to 61. He consistently denied psychotic symptoms or hallucinations, and no delusions were exhibited. The medical records indicate that at times he was easily distracted and his affect was blunted or constricted. He was consistently well-dressed and cooperative, and his impulse control was fair or adequate. On June 2, 2008, and July 28, 2008, he was described as "clinically stable" with a GAF of 61. (R. 289, 300.)
On October 22, 2009, Vanterpool met with his social worker. His mood was euthymic (normal, non-depressed) and he was not paranoid, though he admitted non-compliance with his medication. The notes indicate that Vanterpool's mother informed the social worker that Vanterpool was acting strange and was paranoid about his food being poisoned and people being after him. His GAF was 55. His attitude and behavior were appropriate. He was alert and oriented, exhibited no thought or perceptual disorders, and his cognitive abilities and memory were intact. His insight, judgment, and impulse control were described as fair. The check-box indicating that his attention and concentration were normal, however, was left blank.
On October 24, 2009, Vanterpool saw Dr. Harneja, after failing to show up for his appointments for nearly three months. Vanterpool told Dr. Harneja that he had not taken any of his medications for nearly two months and he was doing okay. Vanterpool reported, however, that his mother told him that he needed to take his medication. Vanterpool informed the doctor that he did not want to get sick again or be hospitalized but he wanted a lower dosage of Seroquel, his prescribed medication. Dr. Harneja described Vanterpool as well-dressed and cooperative, though his affect was constricted. Vanterpool denied having any hallucinations or suicidal or homicidal thoughts. Dr. Harneja described his impulse control as adequate.
Vanterpool saw his social worker again on November 20, 2009. He reported that he was fine: "I am now taking my medication. I have no stressors at home. Everything is good." (R. 363.) His mood was again described as euthymic, with no perceived psychosis. His speech was clear and he had good eye contact. He was oriented to time and place. His GAF was 55. The social worker observed no thought or perceptual disorders and his cognitive ability and memory appeared to be intact. The box next to normal attention and concentration was again left blank.
Vanterpool failed to keep his appointment with Dr. Harneja on November 23, 2009. He indicated that he still had medication left because he was not taking his medication regularly. Vanterpool kept his rescheduled appointment with Dr. Harneja on November 30, 2009. He told the doctor that he needed to see a counselor for his anger problem. He denied having psychological problems as well as any hallucinations or delusions. Vanterpool was only intermittently taking his medication. Dr. Harneja described him as well-dressed, calm, and cooperative, but he was easily distracted. His impulse control was adequate.
Vanterpool missed his scheduled appointment with the social worker on December 21, 2009. He was seen by Dr. Harneja on January 9, 2010, and reported that he was doing well, denying any audiovisual hallucinations, mood swings, or irritability. He reported that he still had medication left and the doctor reinforced the importance of compliance with his treatment plan. His GAF was 61. Vanterpool missed his rescheduled appointment with the social worker on January 18, 2010.
Vanterpool met with his social worker on February 5, 2010. He reported that he was taking his medications daily. His attitude and behavior were appropriate. He was alert and had normal attention and concentration. His memory was intact, and he had no suicidal or homicidal thoughts. His insight, judgment and impulse control were all observed to be fair. He presented no paranoid thinking and his GAF was 60. On February 13, 2010, Vanterpool was seen by Dr. Harneja for medication management. He reported that he was taking his medication regularly though he still would forget some days. His GAF was 61-63, and his attention and concentration were normal.
From March 2010 through October 2010, Vanterpool visited Bronx-Lebanon Hospital Center on numerous occasions and indicated that he was doing fine, reporting no hallucinations or delusions. He was consistently taking his medication, denying audiovisual hallucinations, and demonstrating no paranoia. There were no indications in the medical records of deterioration from the prior assessments with regard to judgment, impulse control, insight, cognitive ability, memory, and attention. His GAF ranged from 55-63, with most GAFs above 60. Dr. Harneja described Vanterpool as clinically stable on multiple occasions. In April 2010, Vanterpool reported that he had one outburst of anger during the prior week but that he handled it. In July 2010, Vanterpool indicated that he was looking for a part time job but was not sure what he wanted to do. The record indicates that Vanterpool missed a few scheduled appointments during this period.
2. Medical Opinion Reports
On April 1, 2010, Dr. Harneja completed a medical assessment form pertaining to Vanterpool's ability to work. Dr. Harneja indicated that Vanterpool's ability to follow work rules and use judgment in an occupation was fair. He identified his ability to relate to co-workers, deal with the public, interact with supervisors, deal with work stresses, function independently, and maintain attention and concentration as poor/none. He also indicated that his ability to understand, remember, and carry out complex job instructions was poor to none, but his ability to carry out detailed (but not complex) or simple job instructions was fair. His ability to maintain his personal appearance, behave in an emotionally stable manner, relate predictably in social situations, and demonstrate reliability was fair. Dr. Harneja believed that Vanterpool would need his mother's assistance to help him manage his benefits.
On April 2, 2010, Vanterpool's social worker filled out a Social Security Disability psychiatric assessment form. Dr. Harneja approved the form. The social worker described Vanterpool as suffering from chronic paranoid schizophrenia, having periods of unstable mood where he was easily distracted, agitated, argumentative, and impulsive. She noted that though Vanterpool denied having auditory or visual hallucinations, he appeared to be responding to internal stimuli and was observed laughing inappropriately. She described his concentration as very poor and marked his GAF as 55-60. She indicated that he should be clinically stable if he continued with treatment.
On March 17, 2011, Dr. Harneja completed another medical assessment form pertaining to Vanterpool's ability to work. In this assessment, Vanterpool's ability to maintain attention and concentration had improved from poor/none to fair. In addition, Dr. Harneja added a note that the longest Vanterpool had worked was four to five months and indicated that in work related situations, Vanterpool was very paranoid. "He thinks people are talking about him and cameras are watching. He is very weary of his peers and cannot function around them in a normal manner." (R. 255.) Otherwise, this assessment was nearly identical to the 2010 assessment. On March 17, 2011, Vanterpool's social worker also completed another psychiatric form, signed by Dr. Harneja, and her responses were also essentially identical to those in the April 2, 2010 document. She did note that Vanterpool no longer laughed inappropriately and was not presenting any delusional thinking.
B. Dr. Dmitri Bougakov
On March 5, 2010, Dr. Dmitri Bougakov, Ph.D. evaluated Vanterpool at the Commissioner's request. During the evaluation, Vanterpool was well-groomed and cooperative. He was coherent and goal directed. His mood was neutral and he was oriented to person, place, and time. Dr. Bougakov described Vanterpool's attention and concentration as intact. His recent and remote memory skills were mildly impaired. Dr. Bougakov described Vanterpool's cognitive functioning as average to below-average and his general fund of information was somewhat limited. Vanterpool's insight was poor to fair and his judgment was fair.
Vanterpool reported to Dr. Bougakov that he was able to do all his chores by himself. He did not spend much time with friends but had a good relationship with his family. Vanterpool was able to manage money and take public transportation. He ...