Citation Nr: 1605180 Decision Date: 02/10/16 Archive Date: 02/18/16 DOCKET NO. 06-10 292 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to an evaluation in excess of 10 percent disabling for residuals of a fracture of the right fifth metatarsal. 2. Entitlement to an initial evaluation in excess of 70 percent disabling for schizophrenia, chronic paranoid type. 3. Entitlement to special monthly compensation (SMC) based on a need for aid and attendance. 4. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Robert V. Chisholm, Attorney WITNESSES AT HEARING ON APPEAL Appellant and Appellant's Mother ATTORNEY FOR THE BOARD Robert J. Burriesci, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from May 1980 to April 1981. These matters come before the Board of Veterans' Appeals (Board) on appeals from rating decisions issued in August 2010, and July 2014, by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran and his mother testified at a video conference hearing before the under signed in March 2014. A transcript of the hearing is associated with the claims file. The issues of entitlement to an evaluation in excess of 10 percent disabling for residuals of a fracture of the right fifth metatarsal, entitlement to special monthly compensation based on a need for aid and attendance, and entitlement to a TDIU were previously before the Board in July 2014 when they were remanded for additional development. FINDINGS OF FACT 1. At all times during the pendency of the appeal, the most probative evidence of record shows that the Veteran's right foot disability is manifested by adverse symptomatology that equates to a moderate foot injury when taking into his complaints of pain but not a moderately severe foot injury and the scope of the service connected disability does not include flat foot, weak foot, claw foot, metatarsalgia, hallux valgus, hallux rigidus, or hammer toe. 2. The Veteran's schizophrenia, chronic paranoid type, does not manifest total occupational and social impairment. 3. The Veteran, as a result of his service-connected disabilities, requires care or assistance on a regular basis to protect him from hazards or dangers incident to his daily environment. 4. The Veteran's service-connected service-connected disabilities preclude substantially gainful employment. CONCLUSIONS OF LAW 1. The criteria for an evaluation in excess of 10 percent rating for residuals of a fracture of the right fifth metatarsal are not met. 38 U.S.C.A. §§ 1155, 5100, 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.321, 3.326, 4.1, 4.2, 4.3, 4.7, 4.10, 4.20, 4.27, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284 (2015). 2. The criteria for a rating in excess of 70 percent disabling for schizophrenia, chronic paranoid type, have not been met. 38 U.S.C.A. § 1155 (West 2014); 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code 9203 (2015). 3. The criteria for SMC based on the need for the regular aid and attendance of another person have been met. 38 U.S.C.A. § 1114, 5107 (West 2014); 38 C.F.R. §§ 3.350, 3.352 (2015). 4. The criteria for an award of TDIU have been met. 38 U.S.C.A. § 1155, 5107 (West 2014); 38 C.F.R. §§ 3.340, 3.341, 4.15, 4.16 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Appropriate notice was provided in April 2010 and June 2010 prior to the initial RO rating decision regarding the claims for entitlement to an evaluation in excess of 10 percent disabling for residuals of a fracture of the right fifth metatarsal and entitlement to SMC based on a need for aid and attendance. The appeal for a higher initial evaluation for schizophrenia arises from the Veteran's disagreement with the initial evaluation following the grant of service connection. Once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. The duty to assist has also been met and appellate review may proceed without prejudice to the appellant. See Bernard v. Brown, 4 Vet. App. 384 (1993). The RO has obtained VA treatment records. An attempt was made to obtain the records regarding the Veteran's application for Social Security Administration benefits. However, a memorandum dated in August 2009 indicates that the records are unavailable. The Veteran was afforded VA medical examinations. Significantly, neither the appellant nor his representative have identified, and the record does not otherwise indicate, any additional existing evidence that is necessary for a fair adjudication of the claims that has not been obtained. Hence, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Higher Evaluation Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Separate diagnostic codes identify the various disabilities. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. Other applicable, general policy considerations are: interpreting reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability, 38 C.F.R. § 4.2; resolving any reasonable doubt regarding the degree of disability in favor of the claimant, 38 C.F.R. § 4.3; where there is a question as to which of two evaluations apply, assigning a higher of the two where the disability picture more nearly approximates the criteria for the next higher rating, 38 C.F.R. § 4.7; and, evaluating functional impairment on the basis of lack of usefulness, and the effects of the disabilities upon the person's ordinary activity, 38 C.F.R. § 4.10. See Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal arises from the initially assigned rating, consideration must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Fenderson v. West, 12 Vet. App. 119 (1999). Moreover, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). A. Residuals of a Fracture of the Right Fifth Metatarsal The Veteran claims entitlement to an evaluation in excess of 10 percent disabling for residuals of a fracture of the right fifth metatarsal. In a December 1984 rating decision, service connection was granted and an initial noncompensable rating assigned for residuals of a fracture of the proximal fifth metatarsal, sustained when the Veteran twisted his ankle in-service. At that time, the RO assigned a diagnostic code "5299." In a June 2000 rating decision, the RO referenced 38 C.F.R. § 4.71a, Diagnostic Code 5284 and increased the rating to the current level of 10 percent. Under Diagnostic Code 5284 a 10 percent evaluation is assigned for moderate foot injuries, 20 percent evaluation is assigned for moderately severe foot injuries, and a 30 percent evaluation is assigned for severe foot injuries. Actual loss of use of the foot is evaluated as 40 percent disabling. Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part that becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.40. The Veteran was afforded a VA medical examination in June 2010. The Veteran complained of progressive pain stiffness and weakness. He denied interval trauma surgery or steroid injection. The response to his current treatment was poor. Rest was partially effective at relieving symptoms. Applying heat or cold did not relieve symptoms. There was no surgery and the Veteran did take Tylenol. The Veteran did not have a history of swelling, heat, redness, stiffness, fatigability, weakness, or lack of endurance. He did have pain at the fifth metatarsal base. He had flare-ups that occurred daily and lasted hours. The flare-ups were caused by prolonged walking/standing, squats, stairs, jogging, jumping, lifting, and carrying. He had partial relief with rest and activity modification. He could stand for 20 minutes and could walk one quarter of a mile. He used a cane for his right foot condition and corrective shoes, shoe inserts, or braces showed fair efficacy. Physical examination did not reveal swelling, instability, weakness, or abnormal weight bearing. There was evidence of painful motion with fifth metatarsal/cuboid articulation and tenderness at the fifth metatarsal base. The examination was not for hammertoes, hallux valgus, hallux rigidus, pes cavus, or flatfoot. There was no skin or vascular foot abnormality. There was no evidence of malunion or nonunion of the tarsal or metatarsal bones. There was no atrophy of the foot. X-rays revealed that the osseous structures are located and allowing for an irregularity of the head of the proximal phalanx of the fifth toe the articular surfaces are preserved and trabecular pattern within normal limits. The impression was that the irregularity of the articular surface of the head of the proximal phalanx is probably due to old trauma The Veteran was diagnosed with healed fifth metatarsal base fracture with residual fibrosis. It had significant occupational effects due to decreased mobility, problems with lifting and carrying, and pain. The resulting work problems were assigned different duties, increased tardiness, and increased absenteeism. There were effects on activities of daily living. The disability prevented exercise and sports. It had a severe effect on recreation, moderate effect on chores, shopping, and traveling, and had no effect on feeding, bathing, dressing, toileting, and grooming. The Veteran was not employed and he stated he was unemployed due to his right foot condition. In May 2014 the Veteran was noted to have pes planus. The Veteran was afforded a VA medical examination in September 2014 and the results were entered in October 2014. The Veteran was noted to be diagnosed with residuals of a fifth metatarsal fracture with adjacent joint proximal interphalangeal (PIP) joint arthritis in the right foot. The Veteran's current treatment was activity modification and cane use. He reported intermittent, dull foot pain. He reported flare-ups that limited prolonged walking and standing. No response was provided regarding flatfoot, Morton's neuroma, hammer toe, hallux valgus, hallux rigidus, acquired pes cavus, and malunion or nonunion of the tarsal or metatarsal bones. The Veteran had mild tenderness to palpation 5th metatarsal, right foot. The severity was mild and the foot chronically compromised weight bearing. The Veteran did not need arch supports, custom orthotics inserts, or shoe modifications. He had not undergone any foot surgery. There was pain that contributed to functional loss. He had pain on weight-bearing. There was no pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or when the foot was used repeatedly over a period of time. He regularly used a cane. Remaining function was not so diminished that amputation with prosthesis would equally serve the Veteran. He had degenerative or traumatic arthritis in the right foot documented by imaging studies. X-ray in September 2014 revealed no new or acute osseous abnormality, stable degenerative changes at the 5th PIP joint, and stable pes planus. The foot impacted on his ability to work by limiting prolonged walking and standing. Entitlement to an evaluation in excess of 10 percent disabling is not warranted. At no point during the period on appeal did the Veteran's foot disability manifest moderately severe or worse symptoms. The term "moderately severe" is not defined by regulation; however, the overall regulatory scheme relating to the foot contemplates 20 percent ratings in cases of problems so disabling that there is objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities or marked tenderness under the metatarsal heads with all toes tending to dorsiflexion. See 38 C.F.R. § 4.71a, Diagnostic Codes 5276, 5278. The record does not indicate that the Veteran's disability approximates such degree of severity The Veteran was noted to have functional loss and the foot impacted the Veteran's ability to work by limiting prolonged walking and standing; however, the Veteran had no pain, weakness, fatigability, or incoordination that significantly limited functional ability during flare-ups or when the foot was used repeatedly over a period of time. The examiner in 2014 categorized the Veteran's foot disability as mild. Therefore, entitlement to an evaluation in excess of 10 percent disabling for the Veteran's right foot disability pursuant to Diagnostic Code 5284 is not warranted. In considering the applicability of other diagnostic codes, the Board has reviewed all criteria pertaining to the foot and finds that Diagnostic Codes 5277, 5278, 5280, 5281, 5282, and 5283, are not applicable in this instance, as the medical evidence clearly does not show that the Veteran has any of the following associated conditions, respectively: bilateral weak foot; acquired pes cavus; bilateral hallux valgus; bilateral hallux rigidus; hallux valgus, or malunion or nonunion of the tarsal or metatarsal bones. The Veteran has been found to have stable pes planus upon x-ray examination; however, there is no indication that this condition is related to his active service. 38 C.F.R. § 4.71a , Diagnostic Codes 5276, 5278, 5280-5283. Therefore, entitlement to an evaluation in excess of 10 percent disabling for residuals of a fracture of the right fifth metatarsal is denied. B. Schizophrenia The Veteran seeks an initial evaluation in excess of 70 percent disabling for schizophrenia. The Veteran was granted entitlement to service connection in a July 2014 RO rating decision, and assigned an evaluation of 70 percent disabling, effective November 15, 2004, pursuant to 38 C.F.R. § 4.130, Diagnostic Code 9201. When evaluating a mental disorder, consideration shall be given to the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. The evaluation will be based on all the evidence of record that bears on occupational and social impairment rather than solely on an examiner's assessment of the level of disability at the moment of examination. It is the responsibility of the rating specialist to interpret reports of examinations in the light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2. Under the provisions of Diagnostic Code 9201 a rating of 70 percent is assignable for occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or work like setting); inability to establish and maintain effective relationships. A rating of 100 percent is assignable for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. When determining the appropriate disability evaluation to assign, the Board's primary consideration is a Veteran's symptoms, but it must also make findings as to how those symptoms impact a Veteran's occupational and social impairment. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013); Mauerhan v. Principi, 16 Vet. App. 436 (2002). Because the use of the term "such as" in the rating criteria demonstrates that the symptoms after that phrase are not intended to constitute an exhaustive list, the Board need not find the presence of all, most, or even some, of the enumerated symptoms to award a specific rating. Id. at 442; see also Sellers v. Principi, 372 F.3d 1318 (Fed. Cir. 2004). All ratings in the general rating formula are also associated with objectively observable symptomatology and the plain language of the regulation makes it clear that the veteran's impairment must be "due to" those symptoms, a veteran may only qualify for a given disability rating by demonstrating the particular symptoms associated with that percentage, or others of similar severity, frequency, and duration. Vazquez-Claudio, 713 F.3d at 118. Psychiatric examinations frequently include assignment of a GAF score, which is defined by DSM-IV as number between zero and 100 percent, which represents the psychological, social, and occupational functioning of an individual on a hypothetical continuum of mental health illness. Higher scores correspond to better functioning of the individual. The GAF score and the interpretations of the score are important considerations in rating a psychiatric disability. See, e.g., Richard v. Brown, 9 Vet. App. 266, 267 (1996); Carpenter v. Brown , 8 Vet. App. 240 (1995). However, the GAF scores assigned in a case, like an examiner's assessment of the severity of a condition, are not dispositive of the rating issue; rather, the GAF score must be considered in light of the actual symptoms of the Veteran's disorder, which provide the primary basis for the rating assigned. See 38 C.F.R. § 4.126(a). In May 2005 the Veteran was noted to use public transit to get around. The Veteran was treated repeatedly for his schizophrenia with injections of Haldol and Haloperidol. In March 2013 the Veteran was treated in the emergency room involuntarily for schizophrenia. The ex parte read that the Veteran had poor insight into his illness, had been noncompliant with his medications, and was leaving the house in the early hours of the morning. Interview revealed the Veteran to be cooperative, though with disorganized thought process. He was unable to state why he was taken to the hospital by the police or why his family members filed the ex parte. He thought his family was after him but could not elaborate. He endorsed auditory hallucinations. He denied command nature voices. He endorsed visual hallucinations of "blurry visions." He denied suicidal or homicidal ideation. He reported that he was eating and sleeping well. He denied recent or previous drug or alcohol use. He admitted that he had not made it to recent appointments for his Haldol decanoate shot. The Veteran was assigned a GAF score of 20. In another treatment note dated in March 2013 the Veteran was noted to have been doing well and to be stable during most of the prior year. He decompensated when he became noncompliant with his psychotropic medication. In another treatment note dated in March 2013 the Veteran's mother reported that the Veteran had insomnia and was restless. He was most likely in the neighborhood walking. He was noted to have missed his injection. He was restless and had recent onset insomnia. He was impulsive. He started taking his clothes off when asked to roll up his sleeve or take off his jacket. The Veteran was discharged the same month after stabilization. On discharge he had good eye contact, organized thought process, and stable thought process content. He was alert, oriented to person, place, time, and situation, and his short and long term memory was intact. Speech was clear, insight intact, judgment intact, and mood stable. He was cooperative and calm, and denied suicidal and homicidal ideations. A VA treatment note dated in May 2013 indicates a GAF score of 50. The Veteran was afforded a VA medical examination in May 2013. The Veteran was diagnosed with schizophrenia, paranoid type. He was on medication and denied overt hallucinations but did at times appear to be reacting to internal stimuli per his mother. The Veteran was noted to have a GAF score of 50. The examiner noted that the Veteran had occupation and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. Examination revealed symptoms of anxiety, suspiciousness, flattened affect, circumstantial, circumlocutory or stereotyped speech, difficulty in establishing and maintaining effective work and social relationships, and difficulty in adapting to stressful circumstances, including work or a worklike setting. He had mild paranoia. Entitlement to an evaluation in excess of 70 percent disabling is not warranted. During the period on appeal the Veteran was consistently treated with monthly injections of antipsychotic medication. He lived with his mother and took walks in the neighborhood. He did not manifest gross impairment in thought process or communication, grossly inappropriate behavior, persistent danger of hurting himself or others, intermittent inability to perform activities of daily living, disorientation to time or place, or memory loss for names of close relatives or himself. On one occasion, lasting less than one month, he was treated as an inpatient when he failed to comply with his medication regimen and decompensated. At that point the Veteran was noted to have hallucinations. However, with the exception of this brief period, his schizophrenia did not manifest total occupational and social impairment. Thus, the preponderance of the evidence is against a finding that the Veteran is entitled to an evaluation in excess of 70 percent disabling and the appeal is denied. C. Extraschedular Consideration The Board finds that the record does not reflect that the Veteran's shoulder disabilities are so exceptional or unusual as to warrant the assignment of a higher rating on an extraschedular basis. See 38 C.F.R. § 3.321(b)(1). The discussion above reflects that the symptoms of the Veteran's right foot and schizophrenia disabilities are contemplated by the applicable rating criteria. The competent medical evidence of record shows that his right foot disability is primarily manifested by pain. The applicable diagnostic codes used to rate the disability provide for ratings based on pain. With regard to the right foot, the effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. 202. His schizophrenia is manifested by occupational and social impairment. The applicable diagnostic code used to rate the disability provides for ratings based upon occupational and social impairment. The effects of the Veteran's disabilities have been fully considered and are contemplated in the rating schedule. Thus, consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). Additionally, the Veteran has not alleged or indicated that the collective impact or combined effect of more than one service-connected disability presents an exceptional or unusual disability picture to render inadequate the schedular rating criteria. See Johnson v. McDonald, 762 F.3d 1362 (Fed. Cir. 2014). Nonetheless, the Board has fully considered the Veteran's additional service-connected disabilities in concluding that referral for consideration of an extraschedular rating is not warranted. Even after affording the Veteran the benefit of the doubt under Mittleider v. West, 11 Vet. App. 181 (1998), there is no additional impairment that has not been attributed to a specific service-connected disability. As such, this is not an exceptional circumstance in which extra-schedular consideration may be required to compensate the Veteran for disability that can be attributed only to the combined effect of multiple conditions. III. Aid and Attendance SMC is payable to a Veteran for anatomical loss or loss of use of both feet, one hand and one foot, blindness in both eyes with visual acuity of 5/200 or less, or being permanently bedridden or so helpless as a result of service-connected disability that he or she is in need of the regular aid and attendance of another person. 38 U.S.C.A. § 1114(l); 38 C.F.R. § 3.350(b). Determination of this need is subject to the criteria of § 3.352. The factors considered to determine whether regular aid and attendance is needed include: inability to dress or undress, or to keep herself ordinarily clean and presentable; frequent need to adjust special prosthetic or orthopedic appliances which by reason of the particular disability requires aid (this does not include adjustment of appliances that persons without any such disability would be unable to adjust without aid, such as supports, belts, lacing at the back, etc.); inability to feed oneself through loss of coordination of upper extremities or through extreme weakness; inability to attend to wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect a claimant from the hazards or dangers incident to his daily environment. It is not required that all of the disabling conditions in 38 C.F.R. § 3.352 be found to exist before a favorable ruling may be made. The particular personal functions which a Veteran is unable to perform should be considered in connection with his or her condition as a whole. It is only necessary that the evidence establish that a Veteran is so helpless as to need regular aid and attendance, not that there be a constant need. Determinations that a veteran is so helpless, as to be in need of regular aid and attendance will not be based solely on an opinion that a Veteran's condition is such that it would require him or her to be in bed. They must be based on the actual requirements of personal assistance from others. 38 C.F.R. § 3.352(a); Turco v. Brown, 9 Vet. App. 222 (1996). To establish entitlement to SMC based on housebound status under 38 U.S.C.A. § 1114(s), the evidence must show that a Veteran has a single service-connected disability evaluated as 100 percent disabling and an additional service-connected disability, or disabilities, evaluated as 60 percent or more disabling that is separate and distinct from the 100 percent service-connected disability and involving different anatomical segments or bodily systems; or, the Veteran has a single service-connected disability evaluated as 100 percent disabling and due solely to service-connected disability or disabilities, the Veteran is permanently and substantially confined to his or her immediate premises. 38 C.F.R. § 3.350(i). The Veteran receives nursing home health visits from VA. Part of the health visits is devoted to medication management. As noted above the Veteran receives routine injection of Haloperidol for his psychiatric disorder. It was noted in March 2013 that the Veteran decompensated when he was noncompliant with his injections and thereafter had to be admitted ex parte for inpatient treatment. Upon admission the Veteran was noted to have poor insight, poor judgment, and to be unable to fully express understanding for need for treatment "so he has been incapacitated." After inpatient treatment the Veteran was prescribed oral Haloperidol and continued to have nursing home health visits including medication management. In July 2014 the Veteran was noted to continue to receive weekly alternating home visits for medication management. In another July 2014 VA treatment note, the Veteran's mother was noted to agree to be more involved in ensuring that the Veteran's pill boxes and all refills are secured. Entitlement to SMC is warranted. In March 2013 the Veteran decompensated and required inpatient psychiatric treatment after becoming noncompliant with his medication. Thereafter, the Veteran was prescribed daily Haloperidol tablets and continued to receive home nursing visits from VA. In July 2014 a July 1987 Court order of Guardianship of person and property was identified in a VA treatment note. The Veteran's mother was the Veteran's appointed guardian. In June 2014 the Veteran was noted to be able to ambulate inside of his home freely and without any difficulties. He was cooperative and reported that he continued to walk about one mile twice a day for exercise. He walked to the store twice a day almost every day. In July 2014 the Veteran was noted to continue to walk around the neighborhood daily. The Veteran was accompanied by his mother to the visit. In July 2014 the Veteran was reported to have been located in the neighborhood at one of his frequent "hang-out" places. In August 2014 the Veteran was noted to have to discontinue pan-handling in the community. Thus, the Veteran is able to walk about in the neighborhood on his own. The evidence reveals that the Veteran requires the assistance of his mother and VA home nursing visits to maintain compliance with his medication to avoid decompensation and inpatient treatment. Affording the Veteran the benefit of the doubt, the Board finds the need for monitoring and medication compliance equates to the need for aid and attendance to protect him from hazards or dangers incident to his daily environment. Entitlement to SMC based on a need for aid and attendance is granted. Entitlement to SMC based upon housebound status is not warranted. The Veteran has reported that he leaves his house and walks to the store twice a day. Thus the Veteran is not housebound. Entitlement to SMC based upon housebound status is denied. IV. TDIU In order to establish entitlement to TDIU due to service-connected disabilities, there must be impairment so severe that it is impossible for the average person to secure and follow a substantially gainful occupation. See 38 U.S.C.A. § 1155; 38 C.F.R. §§ 3.340, 3.341, 4.16. VA defined substantially gainful employment as "employment at which non-disabled individuals earn their livelihood with earnings comparable to the particular occupation in the community where the Veteran resides." See M21-1, Part IV, Subpart ii, Chapter 2(F)(1)(c). In reaching such a determination, the central inquiry is "whether the Veteran's service connected disabilities alone are of sufficient severity to produce unemployability." Hatlestad v. Brown, 5 Vet. App. 524, 529 (1993). Consideration may be given to the Veteran's level of education, special training, and previous work experience when arriving at this conclusion, but factors such as age or impairment caused by non-service-connected disabilities are not to be considered. 38 C.F.R. §§ 3.341, 4.16, 4.19; Van Hoose v. Brown, 4 Vet. App. 361, 363 (1993). Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when the disabled person is, in the judgment of the rating agency, unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that, if there is only one such disability, this disability shall be ratable at 60 percent or more, and that, if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more, and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a). Entitlement to TDIU is warranted. The Veteran is currently in receipt of service-connected benefits that meet the schedular criteria for assignment of a TDIU. The Board finds that the Veteran's service-connected disabilities render him unable to secure and follow a substantially gainful occupation. The record reveals that the Veteran has reported that he is unable to work due to his foot disability. On examination in 2010 the Veteran's foot disability was reported to have significant occupational effects due to decreased mobility, problems with lifting and carrying, and pain. The resulting work problems were that he was assigned different duties, had increased tardiness, and increased absenteeism. The Veteran reported at that time that he was unemployed due to his right foot. In 2014 the Veteran's foot disability was found to impact his ability to work by limiting prolonged walking and standing. Upon psychiatric examination in May 2013 the examiner noted that the Veteran had occupation and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking and/or mood. But he did not have total occupational and social impairment. Examination revealed symptoms of anxiety, suspiciousness, flattened affect, circumstantial, circumlocutory or stereotyped speech, and difficulty establishing and maintaining work and social relationships and difficulty in adapting to stressful circumstances, including work or a worklike setting. The examiner noted that as long as the Veteran is on his medication, he is only mildly symptomatic and able to manage funds. The Veteran submitted an application for TDIU in January 2016 which noted that he had not worked since 1984. A December 2015 Vocational Assessment submitted by the Veteran's representative included a vocational consultant's opinion that the Veteran's service-connected residuals of a fractured right fifth metatarsal and schizophrenia have caused his inability to secure and follow a substantially gainful occupation since leaving the service in April 1981. The consultant based that opinion on a review of the Veteran's claims folder (as provided by the representative) and a phone interview with the Veteran. The consultant detailed the Veteran's educational, medical and employment history. The Veteran, who had a high school education, had work experience as a landscape laborer for a short time after service. Although his service-connected foot disability made that work difficult, the Veteran also felt the fact that he rarely had to come into contact with people made it possible to work, despite symptoms of his service-connected schizophrenia. The consultant noted a progression of symptoms related to both service-connected disabilities since service. The consultant also noted that the Veteran had only performed unskilled labor and had no transferable skills to work at any other exertion level, including sedentary work. The Veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities. Entitlement to TDIU is granted. ORDER An evaluation in excess of 10 percent disabling for residuals of a fracture of the right fifth metatarsal is denied. SMC based on a need for aid and attendance is granted. An initial evaluation in excess of 70 percent disabling for schizophrenia, chronic paranoid type, is denied. TDIU is granted. ____________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs