United States District Court, Northern District of Illinois, Eastern Division
GLORY D. SANDERS, on behalf of MANIECCIA G. FRANCIS, Plaintiff,
CAROLYN W. COLVIN, Acting Commissioner of Social Security, Defendant.
MEMORANDUM OPINION AND ORDER 
SIDNEY I. SCHENKIER, United States Magistrate Judge.
Glory Sanders, on behalf of her daughter, plaintiff Manieccia Francis, seeks an order reversing and remanding the Administrative Law Judge's ("ALJ's") decision denying her claim for disability benefits (doc. # 15), and the Commissioner has filed a motion asking the Court to affirm (doc. # 22). For the reasons that follow, we grant plaintiffs request to remand and deny the Commissioner's motion.
We first review the record, followed by the hearing testimony and the ALJ's opinion.
Ms. Sanders, as Ms. Francis's mother and "plenary guardian, " filed an application for disability benefits on behalf of Ms. Francis on January 27, 2011, alleging that Ms. Francis became disabled and unable to work beginning on September 1, 2010, at 36 years old, due to depression, anemia, psychosis, and degenerative joint disease (R. 69). Ms. Francis has a high school education and has worked as a cashier and customer service associate, but she has never worked at the level of substantial gainful activity (R. 24, 29). She has two children, neither of whom lives with her and her mother. Her teenaged daughter lives in an Illinois Department of Children and Family Services ("DCFS") group home and her teenaged son lives with friends or with his step-grandmother (R. 51-52).
On December 15, 2010, Ms. Francis was brought to Hartgrove Hospital by her sister and police after Ms. Francis was "reportedly very hostile, very agitated, actively hallucinating, talking to self and expressing severe paranoia and suspicious, stating that she has been very angry because her family was trying to hurt her" (R. 243). She was then transferred to Loretto Hospital, which admitted her for closer monitoring and to prevent harm to herself and others after assessing that Ms. Francis was "very guarded, very suspicious, and expressing paranoid delusional thinking, unable to function, unable to care for self with poor insight and judgment" (Id.). While at the hospital, Ms. Francis was at times irritable, isolative, withdrawn, tearful and depressed (R. 253-67). She was diagnosed with psychotic disorder and was administered Risperdal (antipsychotic), Trazodone (anti-depressant) and Haldol (anti-psychotic), among other medications (R. 244, 260).
Ms. Francis was discharged from the hospital on December 27, 2010, and transferred directly to Winston Manor Nursing Home (R. 269). The transfer form indicated that Ms. Francis was independent in bed activity, personal hygiene, dressing, feeding, communication and locomotion (R. 312-13). Discharge notes indicated that Ms. Francis was still considered a potential danger to herself, but that her demeanor was calm and cooperative (R. 268-69).
On April 22, 2011, Ana Gil, M.D., S.C., completed a psychiatric examination of Ms. Francis on behalf of the Department of Disability Services ("DDS"). Ms. Francis reported that in the past, she had been suspicious of her family and had experienced crying spells and feelings of sadness and worthlessness, but she was doing better with medication and no longer had those feelings (R. 302). Ms. Francis reported that she could dress and groom herself and care for her own hygiene, but the nursing home staff cooked, cleaned and shopped for her (R. 304). She also stated that she enjoyed watching television, listening to the radio, and playing bingo (Id.). Dr. Gil observed that Ms. Francis was friendly and engaging, and hopeful about the future (R. 72). She diagnosed Ms. Francis with major depression, single episode, with psychotic features, which was severe and currently in remission with psychiatric treatment (R. 305).
On May 10, 2011, Kirk Boyenga, Ph.D., completed a psychiatric review technique for DDS based on Dr. Gil's examination (R. 73). He opined that Ms. Francis's affective disorder was a severe impairment but did not meet Listing 12.04 (Id.). Applying the Paragraph B criteria, Dr. Boyenga found that Ms. Francis had only mild restriction of activities of daily living and only mild difficulties in maintaining social functioning, but moderate difficulties in maintaining concentration, persistence or pace and one or two episodes of decompensation (Id.). He opined that although Ms. Francis has a history of affective disorder and had a "brief psychotic episode, " she has had "rapid response to medical care" and medication (R. 76). Though Ms. Francis "does little while living in the nursing home, " Dr. Boyenga stated that Ms. Francis's examination responses showed that she is capable of performing simple and detailed routine tasks and leaving home alone, albeit with reduced interpersonal contact (Id.). Dr. Boyenga also noted that Ms. Francis's residence in the nursing home was "apparently related to being homeless and having had a psychotic episode" (Id.).
Ms. Francis also had an internal medicine consultative examination on April 22, 2011, conducted by Fauzia Rana, M.D., at the request of DDS (R. 293). Dr. Rana noted that Ms. Francis was obese, but the only physical impainnent listed was anemia (Id.). Dr. Rana found that Ms. Francis had no physical limitations, and opined that she could "sit, stand, walk, carry, speak, and hear without difficulty" (R. 295-96). On May 11, 2011, based on Dr. Rana's examination, DDS consultant Francis Vincent, M.D., opined that Ms. Francis did not have any severe physical impairments, including any disorders of the back (R. 73).
While at the nursing home, Ms. Francis continued to receive psychiatric treatment and medication. On June 15, 2011, Dr. Bernardo Livas examined her. He reported that Ms. Francis was diagnosed with major depression and psychosis NOS, but her prognosis was "good" and she was "stabilized" and compliant with her treatment plan at that time (R. 326). Dr. Livas noted that her mother wanted to take her home, and Ms. Francis appeared capable of taking care of herself, but he did not issue a discharge order for her because she was still an imminent danger to herself and others (R. 276).
On July 9, 2011, the nursing home filled out a quarterly "resident assessment and care screening" for Ms. Francis, in which Ms. Francis and her guardian participated (R. 327-65). The assessment indicated that Ms. Francis experienced disorganized thinking (including rambling or irrelevant conversation) and delusions (misconceptions or beliefs that are firmly held and contrary to reality), but no symptoms of fatigue, depression, trouble concentrating, or suicidal thoughts (R. 333-36). She required supervision and set-up help for bathing, dressing, eating, personal hygiene, and medication, but needed no help in bed mobility, locomotion and toilet use (R. 340-41). While Ms. Francis sometimes forgot about her anti-psychotic and anti-depressant medication, she did not refuse to take it (R. 353, 364-65). Ultimately, the determination was made that discharge to the community was not feasible (R. 358).
On September 6, 2011, a non-examining DDS consultant, Michael Schneider, Ph.D., reviewed the evidence of mental impairment - including the July 9, 2011 assessment - on reconsideration. He noted that Ms. Francis denied all symptoms of depression and delusions, although a third party stated that she sleeps all the time (R. 85). Dr. Schneider opined that current evidence showed Ms. Francis to be functioning at a normal or near normal level and that her affective disorder and psychotic disorder were not severe impairments and caused only mild restrictions in activities of daily living, social functioning, and maintaining concentration, persistence or pace, and she had suffered only one or two episodes of decompensation (R. 86).
On November 28 or 29, 2011, Ms. Francis was released from the nursing home into the care of her mother, Ms. Sanders (R. 6, 24). Ms. Francis was discharged with several medications, including Risperidone, Trazodone, and Haloperidol (R. 7). However, she stopped taking her medications after she was released from the nursing home, despite her mother's ...