• Assumes responsibility for the ongoing interdisciplinary assessment and development of the individualized plan of care in partnership with the patient, representative (if any), and caregiver(s). • Provides services that are ordered by the physician as indicated in the plan of care. • Provides patient, caregiver, and family counseling. • Provides patient and caregiver education. • Communicates with the physician who is responsible for the home health plan of care and other health care practitioners (as appropriate) related to the current home health plan of care. • Evaluates patient’s functional status (muscle function, endurance, visual coordination, written and verbal communication skills, self-care ability, work capacity, etc.). • Evaluates home environment for hazards or barriers to more independent living. • Identifies equipment needs. • Participates in the development of the total plan of care. • For patients who plan to return to work, performs work capacity evaluation and may refer to specialized vocational training in accordance with Organization policy. • Develops treatment program and establishes goals for improved function. • May teach new skills or retrain patient in once familiar daily activities that have been lost due to illness or injury, in accordance with Organization policy. • May fabricate splints and instruct patient in the use of various types of adaptive equipment to improve function. • May train patient in the use of prosthetic and/or orthotic devices. • Maintains appropriate clinical records, clinical notes, and reports to the physician any changes in the patient’s condition. • Submits these records in accordance with Organization policy. • Participates and contributes in the HHA’s quality assessment and performance improvement program and HHA-sponsored in-service training, case conferences, and other meetings as required by Organization policy to ensure coordinated and comprehensive plans of care for the patients of the Organization. • Identifies patient and family/caregiver needs for other home health services and refers as appropriate. • Instructs patient’s family/caregiver and other Organization health care personnel in patient’s treatment regime when indicated and appropriate. • Supervises Certified Occupational Therapy Assistants according to organization policy and state regulations.