REQUEST FOR CORRECTIVE ACTION

1 IDENTIFYING DATA
TD: NORTH CAROLINA Office Code Social Security Number
Attn: Quality Assurance Unit
- ]
S36 Name of Disabled Person

FROM, OQP Baltimore Disability Qua lity Office Code NH

Branch
Room 216 Oak Meadows, 6401 DATE
R50
Security Blvd, Baltimore, MD 21235
10/20/2010
2. DETERMINATION LEVEL 3. TYPE OF CLAIMANT/BENEFICIARY 4. TYPE OF REVIEW
TITLE II TITLE XVI
DQA III PER
IfG INITIAL o RECON ODIS ODWB DCDS
iI!I 01 DDS Doc
o OTHER
o CDR o CDR
RECON o MEDiCARE o OTHER OSI Dss OBC
ONLY

5. DECISION 6. DIAGNOSIS 7. ONSET 8. DEFICIENCY

PRIMARY Schizophrenic, Delusional AOD I II

~ Favorable
(Paranoid) , Schizoaffective, and Other 06/03/2010 Decisional 0 0
Psychotic Disar EOD
o Unfavorable SECONDARY None Established (Medical 06/17/2010
Documentation f8j 0
Evidence in File But Insufficient to ROD
Establish Diagnos 9. GRACE PERIOD
10. REFERENCES
See below
EXPIRES

'1 ACTION REQUESTED AND RATIONALE

Group I, category 41
Insufficient Medical Documentation to Determine Impairment severity
ISSUE
DDS proposes an initial, Title XVI medical-vocational allowance with a
06/17/10 EOD (date claim filed). Diagnosis is paranoid schizophrenia and
other psychotic disorders. OQP finds the evidence is not yet sufficient
to determine mental impairment severity and duration.

REVIEWERS ANALYSIS
This is an 18-year-old female with 12 years of education and work in the
relevant period as a dietary aide. She filed the Title XVI claim on
06/17/2010, alleging inability to work since 01/10/10 due to psychosis
and mental issues (SSA-336B).

The mother accompanied the claimant to the 07/15/2010 initial

face-to-face interview. No difficulties were observed except for
laughing at things her mother wrote about her on the application and

FOLDER ATTACHED DYES lliIi NO I8l Continued on Attached Sheet

REVIEWER OFFICE APPROVED DATE

MEDICAL I8l YES Cl NO
REVIEW R50 J Poisal 10/20/2010
E. Jerry
MEDICAL REVIEWER
MED NOTE
IN FILE
IfG YES DNO
A. Suansilnnonnse M.D.
Form SSA-1774-U6 (5-1987) a1 (6-2006) (5 Copies: Transmittal, Official folder, ReviEI'N component, Regional disability program, Field office)
 REQUEST FOR CORRECTIVE ACTION

laughing while describing her job to the interviewer.

The mother, who is a~ alleges that prodromal mental symptoms began in 01/2010.
However, treatment was not begun until the 06/03/10 hospitalization at 22t
• due to homicidal threats,
hallucinations and bizarre behavior. Her condition improved quickly
with medical care and she was discharged 06/14/10 to have outpatient
treatment with instructions to take Img of Risperdal in the morning and
3mg at bedtime.

On 06/24/2010, the claimant was evaluated by Dr , a staff

psychiatrist at 3 She presented with
masklike facial expressions, an inappropriate grin, paucity of speech,
and inappropriate laughter. She was not responding to internal stimuli.
She agreed to go on the medication (had she not been taking the
Risperdal?) and answered questions with very few words. She was
oriented to person, place and time. psychomotor activity Was normal.
Speech was normal but halting. Any hallucinations or loose associations
could not be elicited. She was ambivalent. There were no paranoid,
suicidal or homicidal ideations. Sleep was undisturbed and appetite was
good. Insight, jUdgment and illness recognition were poor. The
claimant was to begin taking 4 mg of Risperdal at bedtime. She was to
return in a month.

The 07/21/2010 Third Party Function Report (mother) reveals that the
claimant is given reminders and encouragement to take her medication,
and to dress, bathe, care for her hair, sweep, wash dishes and clean her
room. She prepares sandwiches or frozen dinners utilizing a microwave,
uses pUblic transportation independantly, shops for clothes and shoes,
and watches TV, reads and plays cards well. The claimant does not
socialize with her friends, and cannot remember what happens day to day.
She does well with verbal instructions and, with encouragement, does
well with written instructions. She also gets along well with authority
figures, but her behavior can be rude.

On 7/29/2010, the claimant was initially evaluated by Dr. nB

. . . .IIIr" a psychiatrist at , !, '4 She was
accompanied by the mother and reported the Risperdal had been changed to
Invega because of sedation with the result that she is less tired and
more alert. Chief complaint was schizophrenia with symptoms of gross
disorganization or catatonic behavior. Appearance was age appropriate
and orientation was to person, place and time. Attention and
concentration were underactive, and she only spoke when prompted.

Pa G! 2
EXAMINER'S INITIALS REVIEWER'S INITIALS
EJ ASM
Form SSA-1774A-U6 (5-1987) of (6-2006)
 REQUEST FOR CORRECTIVE ACTION

NAME I~SS~N~===~~~~~~~~====~
Thought organization was goal directed, linear, logical, slow and
concrete. Fund of knowledge was normal. Recent & remote memory,
jUdgment and insight were "stable." Affect was flat, but depressive
symptom was absent as were suicidal/homicidal ideation and
hallucintatons/delusions. Psychomotor activity was retarded. She was
anxious (sometimes ruminates). Sleep was stable on Invega. Dr
....~. .'s plan was to continue the 9 mg once-a-day dose of Invega, try
to obtain enhanced outpatient services for her from 2 and have
her return in 4 weeks. The diagnosis was schizophreniform disorder.

Dr. 's 08/26/2010 report is essentially the same as the one

above. However, the mother indicates that the claimant sleeps 12+ hours
a day. So, to decrease the daytime sleepyness, he reduced the Inveg to
6 mg a day. He was still trying to get her enhanced outpatient services
from Triumph. She was scheduled to return to his office in 4 weeks.

The above MER is insufficient to determine mental impairment severity &

duration and to assess concentration, persistence and pace. The minimal
evidence consists of check blocks and does not give much information
about her mental status.

APPLICABLE POLICY
DI22501.001B4b, medical evidence must be sUfficiently complete and
detailed enough to permit an independent determination about the nature
and limiting effects of an individual's impairment.

REOUESTED CORRECTIVE ACTION

Please obtain an updated psychiatric summary (if possible from the
treating source) with a detailed mental status examination and comments
on treatment response, any adverse reaction to change in medication and
prognosis. Also, please obtain the treatment records f r o m ~

After obtaining the additional documentation, please follow sequential

evaluation and prepare all necessary forms, rationales and notice to
support the resulting determination.

Please return the case to OQP Baltimore for a final review. Thank you.

Pa e 3
EXAMINER'S INITIALS REVIEWER'S INITIALS
EJ ASM
Form SSA-1774A-U6 (5-1987) eI (6-2000)