Citation Nr: 21000670 Decision Date: 01/05/21 Archive Date: 01/05/21 DOCKET NO. 18-47 549 DATE: January 5, 2021 ORDER Entitlement to special monthly compensation based on aid and attendance of another is denied. Entitlement to special monthly compensation based on being housebound prior to October 18, 2019 is denied. FINDINGS OF FACT 1. The Veteran is service connected for paranoid schizophrenia; this is his only service connected disability. 2. The Veteran’s service connected paranoid schizophrenia does not result in loss or loss of use of a hand or foot, permanent impairment of both eyes with central visual acuity of 20/200 or less, a severe burn injury, amyotrophic lateral sclerosis, or ankylosis of a knee or hip. 3. Throughout the period on appeal, the Veteran did not require aid and assistance of another person solely due to his service-connected paranoid schizophrenia. 5. Prior to October 18, 2019, the Veteran was not substantially confined to his dwelling and the immediate premises solely as a result of his service-connected paranoid schizophrenia. CONCLUSIONS OF LAW 1. The criteria for special monthly compensation based on the need for aid and attendance of another have not been met. 38 U.S.C. §§ 1114, 1502, 1521, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.352. 2. The criteria for special monthly compensation based being housebound, prior to October 18, 2019 have not been met. 38 U.S.C. §§ 1114, 1502, 1521, 5107; 38 C.F.R. §§ 3.102, 3.350, 3.352. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from June 1963 to October 1967. These matters come to the Board of Veterans’ Appeals (Board) on appeal from a July 2017 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). Jurisdiction of this appeal is currently with the RO in San Diego, California. This case was most recently before the Board in February 2020, at which time the appeal was remanded to the Agency of Original Jurisdiction (AOJ) for further development. The case has now been returned to the Board for appellate action. On remand, in an October 2020 rating decision, the RO granted entitlement to special monthly compensation based on housebound, effective October 18, 2019. As this was not a full grant of the benefit sought on appeal, the claim remains on appeal and has been recharacterized as shown on the cover page of this decision. AB v. Brown, 6 Vet. App. 35 (1993). Entitlement to special monthly compensation based on aid and attendance or being housebound. The Veteran has applied for special monthly due to needing regular aid and attendance by submitting an examination for housebound status or permanent need for regular aid and attendance completed by a VA provider. See VA Form 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, April 26, 2017. Special monthly compensation for aid and attendance is payable under several circumstances, including if, as the result of the Veteran’s service-connected disability or disabilities, the Veteran; has an anatomical loss or loss of use of both feet, or of one hand and one foot; is so nearly blind as to have corrected visual acuity of 5/200 or less, in both eyes, or concentric contraction of the visual field to 5 degrees or less; is a patient in a nursing home because of a mental or physical incapacity; is permanently bedridden; or, is so helpless as to be in need of regular aid and attendance of another person. 38 U.S.C. § 1114; 38 C.F.R. § 3.350. Determinations as to the need for aid and attendance are based on the actual requirements of personal assistance from others. In determining the need for regular aid and attendance, consideration will be given to the inability of the Veteran to dress himself, or to keep himself clean; frequent need of adjustment of any prosthetic which by reason of the disability cannot be done without aid; inability of the Veteran to feed himself; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect himself from the hazards or dangers of his daily environment. Bedridden will be that condition which, through its essential character, actually requires the Veteran to remain in bed. 38 C.F.R. § 3.352. It is mandatory for VA to consider the enumerated factors within the regulation; at least one of the enumerated factors must be present. Turco v. Brown, 9 Vet. App. 222 (1996). There need not be a constant need but, rather, only a regular need for aid and attendance. Id. It is not required that all of the disabling conditions are present or are due to a service-connected condition to warrant special monthly compensation. Id.; see also Turco v. Brown, 9 Vet. App. 222, 224 (1996). Special monthly compensation is also warranted when a Veteran has a single service-connected disability rated as 100 percent disabling and is permanently housebound by reason of his service-connected disability or disabilities. This requirement is met when a Veteran is substantially confined as a direct result of service-connected disabilities to his dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas, and it is reasonably certain that the disability or disabilities and resultant confinement will continue throughout his lifetime. 38 C.F.R. § 3.350. In the present case, the Veteran is service-connected for paranoid schizophrenia, rated as 100 percent disabling, for the entire period on appeal. This is the Veteran’s only service connected disability. This disability does not result in, nor does the Veteran assert, anatomical loss or loss of use of both feet, or of one hand and one foot; blindness in both eyes with visual acuity of 5/200 or less; being permanently bedridden; being so helpless as to be in need of regular aid and attendance of another person; inability of the Veteran to dress himself, or to keep himself clean; frequent need of adjustment of any prosthetic which by reason of the disability cannot be done without aid; inability of the Veteran to feed himself; inability to attend to the wants of nature; or incapacity, physical or mental, which requires care or assistance on a regular basis to protect himself from the hazards or dangers of his daily environment at any time during the period on appeal. Moreover, prior to October 18, 2019, the Veteran’s service-connected paranoid schizophrenia did not result in the Veteran being substantially confined to his dwelling and the immediate premises. Turning to the evidence of record, the Veteran submitted an April 2017 examination for housebound status or permanent need for regular aid and attendance completed by a VA provider. See VA Form 21-2680 Examination for Housebound Status or Permanent Need for Regular Aid and Attendance, April 26, 2017. At that time, the VA examiner noted the Veteran had diagnoses that included obesity, hyperlipidemia, a large prostate, flat foot, Paget’s disease, cataracts, chronic paranoid schizophrenia, benign essential hypertension and calculi of the kidney and ureter. The examiner further noted that the disabilities that restricted the listed activities and functions were his obesity, Paget’s disease, and chronic paranoid schizophrenia. The April 2017 VA examiner found that the Veteran was able to feed himself but was unable to prepare his own meals due to difficulties with ambulation and transfers as the Veteran required assistance safely navigating the kitchen area of his home and needed assistance in bathing and tending to other hygiene needs due to difficulties with transfers and ambulation. The examiner noted that the Veteran required assistance with activities of daily living, instrumental activities of daily living, and safely navigating the bathroom area of his home, that the Veteran was not legally blind and did not require nursing home care and that he required medication management but needed medication reminders. The Veteran presented as alert and oriented to all spheres, that he did not have restrictions with his upper body and that he had ambulation difficulty due to his left hip arthritis. The examiner noted that the Veteran had no restrictions of the spine, trunk, or neck and no problems ambulating because of his left hip advanced arthritis. The examiner noted the Veteran needed assistance with ambulation due to his left hip advanced arthritis, and used a walker for locomotion. Of record is a July 2017 statement submitted by the Veteran’s caretaker, P.G. In her statement, she stated that she was the live-in caretaker for the Veteran and had been living with him for over a year. She stated the Veteran used a walker, had needed hip replacement surgery and that the Veteran had fallen in the past. Further, she stated the Veteran had cataracts and could not see out of one of his eyes as a result. P.G. stated that due to these disabilities, the Veteran could not cook, clean, maintain his medication, maintain his hygiene, or maintain the household. Moreover, she stated the Veteran lost his driver’s license, had clouded judgment due to his psychiatric disorder and that she had to do all of the cleaning, cooking, washing his clothes, and maintaining cleanliness of the house. Further, she stated that the Veteran could not maintain his own medication and was not taking his medication properly. In his July 2017 notice of disagreement, the Veteran stated that his mobility was not stable, that he had cataracts, that he could not see, that he could not cook, and that he could not handle his medication. He stated that he needed help with all of his personal hygiene and showers, and that his live-in caretaker handled everything for him. In his August 2018 substantive appeal (VA Form 9), the Veteran stated that he had a live-in caretaker and needed help with dressing, bathing, “everything,” and eating. He reported that he had severe arthritis in both knees and hips and was suffering from schizophrenia. Of record is an April 2019 neuropsychology consult by Dr. J.F. The Veteran reported gradual onset of mild memory and attention difficulties over the past few years. He was able to describe the reasons for his current admission, course of treatment, and medical status. Functional status review showed that the Veteran required assistance with dressing, bathing, toileting, and transferring and noted that these difficulties were due to physical limitations. The Veteran reported that his driver’s license had been revoked six years prior due to multiple motor vehicle collisions (eight collisions over three years), which he attributed to poor judgment. He required assistance from his son for medication management and that he sometimes forgot to take medication. He was dependent on his son for financial management and his daughter thought he needed a fiduciary; the Veteran noted he did not have difficulties with managing finances. The April 2019 provider noted that behavioral observations and mental status examination showed the Veteran was alert, attentive, grossly oriented to time, place, person, and situation and speech was normal in rate, volume, pitch, and prosody. The provider noted that there were no frank word finding difficulties or paraphasis were observed, that the affect was normal in range and intensity, that there no suicidal or homicidal ideation was reported, that thought processes appeared linear and goal-oriented and that there did not appear to exhibit visual acuity difficulties during testing. The provider noted that hearing appeared adequate for the purposes of the evaluation, that he used a wheelchair for mobility, that there was no abnormal upper extremity movements were observed that he appeared to have adequate task engagement and persisted on tests to the best of his ability. Testing results showed average premorbid functioning, impaired global cognitive status, largely oriented to time and fully oriented to place, basic attention borderline impaired, processing speed borderline impaired, phonemic fluence impaired, semantic fluence borderline impaired, judgment of line orientation was borderline impaired and reproduction of a complex figure was impaired. Testing results further showed that learning of both uncontextualized and contextualized verbal information was borderline impaired, spontaneous recall was low average, recognition discrimination was borderline impaired, recall of passively learned complex figure was impaired, executive functioning was within normal limits, cognitive flexibility was impaired, adaptive functioning was low average and his performance on a financial management task was average. In sum, Dr. J.F. had neuropsychological profile that was notable for deficits in attention, processing speed, executive functioning, visuospatial skills, and visual memory; and denied significant depressive symptoms. Functionally, Dr. J.F. found the Veteran required assistance with many activities of daily living (ADLs) and independent ADLs (IADLs), formerly due to his physical limitation. However, it was unclear to what extent his psychiatric condition may have interfered with his IADL functioning. In considering cognitive decline, Dr. J.F. found that some areas of weakness detected in this examination was not uncommon for individuals with schizophrenia; however, there was no prior neuropsychological evaluation as a basis for comparison, and it was difficult to determine whether there was change compared to his individual baseline. She noted that the Veteran’s history indicated cognitive difficulties may have been longstanding, and may be exacerbated by physical difficulties. The Veteran demonstrated an adequate understanding of his medical conditions as well as current admission and treatments; and his performances were within normal limits. Therefore, Dr. J.F. determined the Veteran appeared to possess medical and financial decision-making capacity at that time. Of record is an October 18, 2019 VA neuropsychological assessment note by Dr. J.F. The Veteran was referred for reevaluation due to new concerns about his judgment and decision making capacity and to clarify a cognitive diagnosis. Dr. J.F. noted that at a previous March 2019 neuropsychological assessment, testing revealed deficits in attention, processing speed, aspects of executive functioning, verbal fluence, visuospatial skills, and visual memory; and exhibited some difficulties acquiring verbal information (both uncontextualized and contextualized), however his delayed verbal memory performance was adequate. He denied clinically significant depressive symptoms. Functionally, he required assistance with many ADLs and IADLs (formerly due to physical limitations). Performance on measures of adaptive functioning revealed that the Veteran had adequate procedural knowledge of factors affecting health and safety and money management. However, a close review of the raw data from the prior money management assessment revealed that the Veteran lacked attention to detail, was observed to write down the incorrect amount on the written section of the check, and made errors with some tasks requiring math calculation. Previously, it was concluded that it was unclear to what extent the Veteran’s paranoid schizophrenia was contributing to his cognitive and functional impairments, that it was thought that the Veteran’s physical problems exacerbated his cognitive difficulties and he was diagnosed with mild neurocognitive disorder, unspecified. However, he was thought to possess medical and financial decision-making capacity given his intact performance on adaptive functioning measures. At the October 2019 neuropsychological assessment, the Veteran acknowledged having problems with memory and denied other significant cognitive concerns or changes since his previous evaluation. The Veteran had previously been found to have capacity for financial and medical decision-making. However, recent series of events renewed concerns about his decision-making capacity. First, the Veteran had recently donated $5,000.00 to a church and the unusually large amount of money raised the question about whether he had the capacity to manage his own finances. The Veteran indicated that $5,000.00 was approximately 10 percent of his income and that he was tithing in line with his religious values. He stated that he preferred to donate a lump sum annually and that he did not plan to donate any more money until the following year. Dr. J.F. noted that there were two recent occasions during which the Veteran left the inpatient building where he lived and could not be promptly located by the staff. The first incident occurred in July 2019 when the Veteran traveled to the fishing dock in his wheelchair with the assistance of another veteran and the other veteran was unable to return the Veteran and left his stranded at the fishing dock. The Veteran then wheeled himself to a different building and asked for assistance back to his unit. When the staff found him, they found him socializing with his friends and stated that his friends would have returned him. Prior to this incident, the Veteran had authorization to leave his unit and reported that he signed out appropriately on that day; however, following this incident, the Veteran was instructed not to leave the building and curtilage without staff escort. The second incident occurred in October 2019 when the Veteran left the campus in another veteran’s fan to attend church services in a different city. The Veteran was discovered missing in the morning, approximately one hour after he was seen leaving the ward. He did not have a cell phone and could not be contacted directly. The VA police and his daughter were promptly notified. It was discovered that the Veteran wrote “prayer breakfast and festival” on the unit sigh out sheet prior to leaving, and he reportedly told his roommate and food service worker that he was attending a prayer breakfast that morning and would be missing breakfast and lunch. It was not indicated whether the Veteran specified that this event was off-campus. Staff was able to contact the veteran who transported the Veteran off campus, who confirmed that the Veteran was with him. Unbeknownst to the Veteran, the driver of the van had a suspended driver’s license. Following this event, the Veteran was placed on unit restriction with safeguards in place pending this neuropsychological evaluation. Upon interview, the Veteran was adamant that he was unaware he needed a day pass to leave the inpatient facility; and stated that he would not have traveled with the other veteran had he known the circumstances of that veteran’s license. The Veteran indicated he would request a day pass, required for his safety, if he wanted to leave the unit. The Veteran reportedly made another attempt to leave the unit with a volunteer in October 2019, and required another re-education regarding the attempt. Dr. J.F. noted that the Veteran depended on staff for assistance for most basic activities of daily living due to his physical limitations, that he used a wheelchair for mobility and reported that he managed his own finances without difficulty and that he reported he paid his bills promptly each month. The provider noted that the Veteran’s daughter previously noted that she believed the Veteran may need a fiduciary for finances, that he did not currently use recreational substances or alcohol, and had recently quit smoking tobacco, that the Veteran was separated from his wife and had two living children, and one deceased daughter and that he lived with his son prior to his inpatient admission. Behavioral observation and mental status examination showed that the Veteran was polite, cooperative, alert, attentive and that he was grossly oriented to time, place, person, and situation. The provider determined that the Veteran’s speech somewhat dysarthric but otherwise normal in rate, volume, pitch, and prosody, that he his receptive and expressive language appeared intact, that there were no frank word finding difficulties or paraphasis were observed and euthymic mood. The provider determined that the Veteran’s affect was normal in range and intensity, that there were no suicidal or homicidal ideations reported, that thought processes appeared linear and goal-oriented, that there did not appear to exhibit visual acuity difficulties during testing but reported that he left his reading glasses at home when he was admitted to the hospital and that his hearing also appeared adequate for the purposes of the evaluation. The provider further found that the Veteran used a wheelchair for mobility, that no abnormal upper extremity movements were observed, that the Veteran performed in the valid range on an embedded measure of performance validity during testing and that he appeared to have adequate task engagement and persisted on tests to the best of his ability. Dr. J.F. noted that, on interview and following testing, the Veteran demonstrated an adequate understanding of his medical conditions and recent state of his health. However, the provider noted that the Veteran’s performance on an adaptive functioning measure of a range of factors pertaining to health and safety was in borderline impaired range as many of his responses were either incomplete, demonstrated concrete reasoning, or required additional querying. The provider noted that when taken together with his cognitive impairments, the Veteran did not appear to have the cognitive capacity for independent decision-making regarding his medical care at this time. The provider explained that functioning capacity interview and objective testing showed the Veteran appeared to have adequate knowledge of his own finances and expenses, that he reported that his recent religious donation was consistent with his personal and religious values, that it was unclear to what extent he had an ongoing relationship with this particular church, and it was unknown whether the practice of tithing 10 percent of his income to a church had been longstanding for the Veteran or if this was something new. The provider noted that the Veteran’s performance on an objective measure of financial management suggested relatively well-preserved procedural knowledge with regard to financial matters and that he appeared to have impairment with completing written arithmetic, which is necessary for financial capacity, that occurred during the prior assessment. The provider determined that, based on his verbal memory impairment, executive functioning deficits, and impaired math computation skills, the Veteran did not appear to have the cognitive capacity to independently engage in complex financial decision-making nor could he perform the required math calculations at that time. The provider further determined that the Veteran appeared to have the cognitive capacity to be involved in discussions regarding his personal financial matters and that the Veteran would likely benefit from increased involvement of his daughter and son to ensure that his finances were being appropriately managed. In sum, Dr. J.F. found that the Veteran’s cognitive disorder had not advanced since his previous evaluation but further review suggested that the Veteran met the criteria for mild dementia and that his cognitive impairments were likely related to the longstanding diagnosis of schizophrenia, with additional contributions of his physical impairments. Therefore, Dr. J.F. found the Veteran would be considered a vulnerable adult and was at risk of exploitation by others. In addition, the provider found that the Veteran was not shown to currently have the capacity for independent financial or complex medical decision-making, although he was thought to be able to participate in discussions about hi finances and healthcare with his appointed power of attorney and healthcare proxy. The provider determined that the Veteran was thought to be capable of following highly concrete, structured and written guidelines but based on his marked difficulties with verbal list learning and his concrete reasoning, he would require a written copy and oral repetition of these guidelines. Dr. J.F. diagnosed probably major neurocognitive disorder, due to mixed etiologies, and mild paranoid schizophrenia. Of record is a November 2019 VA Form 21-4138 Statement in Support of Claim submitted by the Veteran’s VA treatment provider. In that statement, it was indicated that the Veteran was currently inpatient at a VA medical center and living in the long-term care unit. The Veteran underwent a repeat neurophysiological assessment performed by the neuropsychologist, Dr. F. on October 18, 2019. As a result, the Veteran was evaluated to require help managing his financial affairs. This November 2019 VA Form 21-4138 was submitted to initiate the fiduciary process to determine the most appropriate individual to assist the Veteran with his money management. The Veteran was afforded a VA examination in June 2020. At that time, the examiner found the Veteran was not permanently bedridden, that he was currently hospitalized from March 2020, that he could not travel beyond his current domicile, and traveled to the examination alone. The examiner noted that the Veteran participated in physical therapy, eating, and sitting, on a daily basis, that the Veteran could walk without the assistance of another person, that he did not need aid for ambulation, that he could leave his home for medical care only and that his functional impairments were not permanent. The examiner noted that the Veteran’s best correct vision was not 5/200 or worse in both eyes, that his cervical and thoracolumbar spine did not have limitation of motion or deformity, that the functioning of the upper extremities was normal without upper extremity amputation, that the Veteran had normal bilateral upper extremity strength, that he had normal ability for self-feeding; that he had normal ability to dress and undress and that he had normal ability to self-bathe. The examiner noted that the Veteran had normal ability to self-groom, that he normal toileting ability, that the functioning of his lower extremities was normal without lower extremity amputation, that there were no bilateral lower extremity functional limitations found and that weight-bearing was normal. The examiner further found that the Veteran’s propulsion was normal, that the Veteran did not know the amount of his benefit payment, that he was not able to prudently handle payments, that he did not know the amount of his monthly bills and could not personally handle money and pay bills. The VA examiner found the Veteran was not capable of managing his financial affairs. The Veteran was afforded a VA examination in October 2020. At that time, the examiner found the Veteran required prompting with activities of daily living, such as dressing and hygiene. The examiner noted that the Veteran was ambulatory but a fall risk, that he often ambulated via wheelchair, that he did not use any specific prosthetic or orthopedic devices and that he had an inability to attend to the wants of nature. The examiner found that the Veteran was able to feed himself, that there did not appear to be any gross loss of coordination of the upper extremities or extreme weakness and that he had mental incapacity to the degree that it required care or assistance on a regular basis to protect the Veteran from hazards or dangers incident to his daily environment. The examiner determined that for practical purposes, the Veteran was substantially confined to his house (ward or clinical areas, if institutionalized or immediate premises) due to his service-connected paranoid schizophrenia and it was reasonable to assume this would remain throughout his lifetime. Additionally, the Board has carefully reviewed the Veteran’s extensive treatment records and finds that such records generally reflect that prior to May 2018, the Veteran lived at home alone or with his son; and after May 2018, the Veteran was hospitalized and lived inpatient at a VA medical center. Prior to May 2018, the Veteran typically presented to medical appointments unaccompanied with difficulty ambulating, reported a history of falls and reported difficulties with organizing and remembering to take medication. See e.g. VA treatment record, April 7, 2017. The Veteran also generally reported he was capable of some IADLs, to include bathing and washing his clothes and had a caretaker who helped with other activities. See e.g. VA treatment record, January 31, 2017. The Veteran was generally shown to not be cognitively impaired and lived alone. See e.g. VA treatment record, November 13, 2017. Beginning May 2018, the Veteran was typically shown to have fluctuating independence with activities of daily living. At times, the Veteran was evaluated as generally independent in mobility and personal hygiene; and at other times the Veteran was evaluated as requiring the maximum level of assistance with activities of daily living. See e.g. VA treatment record, December 26, 2018 (indicating independent mobility on unity; limited assistance with bed transfer; and independent with personal hygiene after setup); see e.g., VA treatment record, May 30, 2018 (indicating the Veteran was independent after setup for personal hygiene, had independent mobility on unit, and independent with toileting); see e.g. VA treatment record, June 01, 2018 (indicating the Veteran required the maximum level of assistance with personal hygiene); see e.g. VA treatment record, December 26, 2018 (indicating that the Veteran was assisted with all activities of daily living as needed, and moving around and going outside by himself using his wheelchair); see e.g. VA treatment record, March 18, 2020 (indicating the Veteran had self-performance with supervision for hygiene). Notably, the Veteran’s VA treatment records from 2020 seem to indicate the Veteran required additional assistance and dependence with his activities of daily living. See e.g., VA treatment record, May 24, 2020 (indicating that the Veteran had total dependence with toileting, self-performance with eating, total dependence with bed mobility, total dependence with personal hygiene, total dependence with bathing, and total dependence with dressing). However, the Veteran’s VA treatment records continue to indicate that he maintains fluctuating independence with his activities of daily living. See e.g. VA treatment record, May 25, 2020 (indicating the Veteran was independent with bed mobility, eating, toileting, transfer, and locomotion; with extensive assistance required for personal hygiene and dressing). Additionally, of note, VA treatment records from July 2020 seem to indicate the Veteran reported communicated with the Holy Spirit, and that he believed he could travel off campus in spite of restrictions because what God says is more important; and his demeanor and behavior suggested psychiatric decompensation. See e.g. VA treatment record, July 28, 2020. The Board has considered all of the evidence of record, but the preponderance of the evidence shows that the Veteran’s service-connected disabilities alone are not so severe as to cause him to require regular aid and attendance or to be permanently bedridden at any time during the period on appeal. While the evidence indicates that the Veteran does benefit from the assistance of his friends and family, the impairments the Veteran experiences are caused by his physical impairments, to include obesity, hyperlipidemia, a large prostate, flat foot, Paget’s disease, cataracts, chronic paranoid schizophrenia, benign essential hypertension, and calculi of the kidney and ureter. Additionally, at no time during the period on appeal has the Veteran been shown to have anatomical loss or loss of use of both feet, or of one hand and one foot, blindness in both eyes with visual acuity of 5/200 or less, be permanently bedridden, being so helpless as to be in need of regular aid and attendance of another person, the inability of the Veteran to dress himself, or to keep himself clean, the frequent need of adjustment of any prosthetic which by reason of the disability cannot be done without aid, the inability of the Veteran to feed himself, the inability to attend to the wants of nature or incapacity, physical or mental, which requires care or assistance on a regular basis to protect himself from the hazards or dangers of his daily environment at any time during the period on appeal. The Board notes that the Veteran’s functioning varied throughout the period on appeal as evidenced by his extensive VA treatment record. However, the Veteran has been consistently shown to be able to feed himself, was independently mobile with the use of a wheelchair, and required assistance with activities of daily living due to his physical limitations. See e.g. April 2017 VA examination for Housebound Status (indicating the Veteran required assistance for activities of daily living due to his hip arthritis); see e.g. July 2017 lay statement by P.G. (indicating the Veteran required assistance due to his physical disabilities, and some assistance with medication management); see e.g., August 2018 VA Form 9 (indicating the Veteran needed help with “everything” due to severe arthritis in his knees, hips, and schizophrenia); see e.g. April 2019 and October 2019 neuropsychology consults by Dr. J.F. (indicating that his functional difficulties were due to physical limitations); and see June 2020 VA examination report (indicating the Veteran was not permanently bedridden, and could walk without the assistance of another person). Moreover, the Board notes that the Veteran lived alone prior to May 2018, and was able to attend medical appointments alone and generally reported that he was capable of some IADLs, to include bathing and washing his clothes. See e.g. VA treatment record, January 31, 2017. As such, the Board finds that the Veteran’s service connected paranoid schizophrenia alone was not so severe as to cause him to require regular aid and attendance or to be permanently bedridden at any time during the period on appeal. However, where a Veteran does not meet the qualifications for aid and attendance, housebound benefits may be applicable. For the entire period on appeal, the Veteran was in receipt of a 100 percent schedular rating for his service-connected paranoid schizophrenia. However, service connection was not in effect for any other disability, and as such, he was not in receipt of a separate 60 percent rating. Further, prior to October 18, 2019, the clinical evidence of record does not establish, and the Veteran has not alleged, that he is housebound as a result of his service-connected condition. This requirement is met when a Veteran is substantially confined as a direct result of service-connected disabilities to his or her dwelling and the immediate premises or, if institutionalized, to the ward or clinical areas and it is reasonably certain that the disability or disabilities will continue throughout his or her lifetime; circumstances not shown in this case. 38 C.F.R. § 3.350(i). In this case, the Veteran was not housebound. As noted above, the Veteran lived alone prior to May 2018 and was not substantially confined to his home at any period. Specifically, the Board notes that the Veteran was able to attend medical appointments alone and even as recently as October 2019, the Veteran was shown to leave his inpatient VA medical center long-term unit. See e.g. October 2019 neuropsychological assessment (indicating the Veteran left the inpatient center to go to a fishing dock with a friend; and the Veteran left to attend a church service in a different city). The Board recognizes the statements of the Veteran to the effect that his disabilities render him housebound and/or require the aid and attendance of another. With respect to these contentions, the Board acknowledges that the Veteran can attest to factual matters of which he has first-hand knowledge, such as ongoing physical problems and symptoms. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). However, to the extent that the Veteran has reported that he was unable to perform tasks due to his service-connected paranoid schizophrenia, such assertions are outweighed by the objective clinical findings suggesting that the Veteran is able to perform such activities. (Continued on the next page)   Accordingly, special monthly compensation based on the need for aid and attendance another person or on account of being housebound is not warranted for any period on appeal and special monthly compensation based on being housebound is not warranted prior to October 18, 2019. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. The preponderance of the evidence is against the Veteran’s claims regarding special monthly compensation. As such, that doctrine is not applicable in the instant appeal, and his claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Mariah N. Sim, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.