• 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 patient, caregiver, and family counseling; • Provides patient and caregiver education; • Prepares clinical notes, and progress summaries based on the attainment of goals; • Communicates with the physician who is responsible for the home health plan of care; • Provides physical therapy services to patients according to a written physician's plan of care; • Evaluates home environment; • Assesses for muscle strength, mobility, gait, ROM—potential for rehab; • Directing physical therapy treatment; • Instructing patients and families/caregivers in the use and care of therapeutic appliances; • Determining priority needs for physical therapy; • Reporting to physician patient’s reaction to treatment or changes in condition; • Initiates physical therapy program and instructs other personnel and/or family/caregiver members in certain phases of physical therapy; • May train patient in the use of prosthetic device; • Identifies patient and family/caregiver needs for other home health services and refers as necessary; • Participates in discharge planning for patient; • Provides in-service education programs for nursing organization personnel as needed; • Participates in peer consultation process; • Supervises Physical Therapy Assistants according to organization policy and state regulations.