Initiates and establishes comprehensive individualized nursing plan of care within 24 hours, reflecting admission through discharge planning; Develops patient centered goals, in collaboration with clients, their families and the rehabilitation team that are oriented to wellness behavior, are reality based, encourage socialization with others and promote maximal independence for patients with disabilities or chronic conditions. Job Responsibilities: Utilizes basic physical and psychosocial skills by identifying actual/potential nursing/clinical problems based on bio-psycho-social- spiritual assessment data of the client and their families or caregivers and documents findings.