Develops and initiates the plan of care and 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); Initiates proper preventative and rehabilitative nursing procedures and 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; Prepares clinical notes; 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. Supervises Licensed Practical Nurses (LPNs)/ Licensed Vocational Nurses (LVNs) and/or Home Health Aids (HHAs)/Certified Nursing Assistants (CNAs), as directed.