Sarah Coddington & Hannah Linville

Table of Contents
Mission & Vision Statement .................................................................................................................... 3
Needs Assessment ...................................................................................................................................... 3
SWOT .......................................................................................................................................................... 4
Location ...................................................................................................................................................... 6
Organizational Chart................................................................................................................................ 6
Job Descriptions ........................................................................................................................................ 6
Services and Scope of Practice ............................................................................................................. 10
Goals and Objectives............................................................................................................................... 11
Budget........................................................................................................................................................ 12
Marketing ................................................................................................................................................. 18
Floor Plan................................................................................................................................................. 24
Program Evaluation ............................................................................................................................... 26
Documentation ........................................................................................................................................ 29
Policy and Procedure.............................................................................................................................. 38
Quality Assurance ................................................................................................................................... 45
Concept Map ............................................................................................................................................ 48
Regulated By ............................................................................................................................................ 48
References ................................................................................................................................................ 49
 Mission & Vision Statement

Mission Statement: To provide a family centered, community-based occupational therapy

services for children under the age of three who have a developmental delay or disability or are
at risk for developing a developmental delay or disability in West Virginia.

Vision Statement: By supporting both the child and caregivers we strive to ensure that children
and their families can achieve maximum participation in all areas of their lives, specifically in
their homes and communities.

Needs Assessment

● Who
○ Sarah Coddington
○ Hannah Linville
● What
○ Birth to Three Early Intervention Services - Get Up and Grow
● When
○ May 2020
● Where - our location
○ Lincoln County, WV
● Why - why are we putting it there “Because this county has highest peds population
○ 2019 County Health Rankings for the 55 Ranked Counties in West Virginia
● Lincoln County ranked 50/55
○ Highest rate of children born addicted to opioids 106.6 per 1,000 births
○ Population (2018)
■ Lincoln County Population: 20,599
■ Lincoln county persons under 5: 5.7%
■ Child under 5 population: ~1,174
■ Percent of population who are children with disabilities ages 3 through 5:
8.7
○ Need to find BTT therapists in the area
○ Part of Region IV
■ Rural area
■ Neighboring Cabell county had highest overdose rate
○ Poverty: 24.9% of the population live below the poverty line - higher than the
national average of 13.1%
■ Birth to three is free to families, no copay
○ Rural area with no pediatric clinics
○ Low health literacy - need to find statistics
 ○ High rate of children in foster care - 6592 as of December 2019
■ Opioid crisis
■ Grandparents raising children
● Risk of low health literacy increases
● Personal health factors impeding ability to care for infants
● how - don’t answer with needs assessment, will get into this with budget

SWOT

● Strengths
○ External Factors
■ Strong support from local pediatricians
■ Substantial need: Highest rate of children born addicted, presumed high
rate of children with disability and/or at risk that qualify for BTT services
■ Support from local politicians
■ Limited competition
○ Internal Factors
■ Determined leadership
■ Creative, business savvy
■ Extensive experience working with children birth to three and their
families
■ Funds available for startup
● Weaknesses
○ External Factors
■ Large caseload we may have to take on
■ Limited public education on OT
■ Negative perception of healthcare providers
■ Small infrastructure in Lincoln County, WV
○ Internal Factors
■ Limited financial and legal expertise (may have to bring in outside help
ex. Account, lawyer)
■ Minimal experience on business startup/starting a company
■ Lack of management experience
■ Limited experience with home health/community practice
● Opportunities
○ External
■ Local child services that could provide partnership and a source of
referrals
● Right From The Start
○ https://www.wvdhhr.org/rfts/
 ● ABLE families
○ https://ablefamilies.org/programs/
■ Constant media on opioid epidemic and rise in children entering foster
care
■ Need for healthcare providers in rural areas
■ WV Birth to Three Early Intervention System State Plan under Part C of
the Individuals with Disabilities Education Act (IDEA)
● Funding: $80,231,079 (19-20) fiscal year. ~1.454 million per
county
○ Internal
■ Expansion of services into bordering counties
■ Increase in financial resources (income, profit) that could be used to
expand and promote business
■ Underserved area with an increasing need for healthcare providers
● Increasing number of children requiring early intervention services
■ With the growth of business, the ability to hire more OTs (and possibly
other healthcare professionals)
● Be able to provide more service to more clients and wider areas
● Bring more people to the rural areas
● Threats
○ External Factors
■ Unreliability of clients (cancelling sessions, not showing up, etc.) is
money and time lost for the business
■ Change in healthcare legislation
■ Location- have to travel to rural areas
● Seasonal weather causing delays or inability to travel
■ Competition from other Birth to Three companies
○ Internal Factors
■ Limited start up capital
■ Instability/unpredictability of business start up (job security, cash flow,
etc.)
■ Need to procure health insurance, liability insurance, etc.
■ First time business owners - inexperienced
 Location

Housed in private residence, office will be in therapist’s residence (basement converted to office
space) in Lincoln County, Hamlin, WV.

Address: 300 Maple St., Hamlin, WV, 25523

Organizational Chart
 Job Descriptions

WV Birth to Three Regional Administrative Unit

Position is directly responsible to the WV Birth to Three Program director and works in
conjunction with other Birth to Three and DHHR personnel, including finance, mis, Medicaid,
etc. To carry out the following duties: act as liaison to facilitate problem resolution and assure
compliance with federal, state and local regulations, laws, policies and procedures governing the
WV Birth to Three Program or technical area. Provide Birth to Three policy interpretation and
guidance for Birth to Three regional administrative units (RAU's), in order to ensure
implementation of program requirements under state statute and federal regulations of the
Individuals with Disabilities Education Act (IDEA) assist locally contracted RAU's with
technical plans of correction following quality assurance monitoring. Represents Birth to Three
System on strategic state level interagency workgroups and assists with local/community agency
working relationship agreements. Provide state oversight for the department's WV Birth to Three
System representatives to develop/evaluate regional work plans in order to implement program
objectives. Uses independent judgement in determining action taken in both the administrative
and operational aspects of the area of assignment. Identify provider training needs across
assigned geographic region since all enrolled providers must meet program established
credentialing requirements. Recommend changes to address performance gaps as required by the
federal funding (Part C/IDEA). Assist in development of performance measures for evaluation of
Birth to Three System outcomes. Recommends operational changes to facilitate efficient and
effective accomplishment of goals or delivery of service. Informs director of technical area,
program, or service deficiencies and recommends improvement. Identifies professional
development needs of participating providers, which include child development specialists,
occupational therapists, nurses, social workers, physical therapists, speech and language
pathologists. Work in conjunction with program director and other state representatives to
develop and evaluate regional work plans to implement program objectives. Arrange for
community forums to assure community engagement. Assists in the development of the policy
and procedure manual for the WV Birth to Three Program and operational guidance. Represents
the department at local planning meetings and is expected to provide public information
functions on a regular basis, including meeting routinely with physicians, higher education, and
various medical specialty organizations such as AAP, FAAP, etc. Assists WV Birth to Three
technical assistant coordinator with development of technical assistance materials and local
administrative reviews. Individual must be able to use independent judgement and analytical
skills while working with regional grantees, enrolled providers, state and local interagency
partners. Must be able to communicate effectively, both orally and in writing, with a wide variety
of stakeholders including grantees, vendors, higher education representatives and other state
agencies policy makers. Must be knowledgeable of IDEA, FERPA, and ADA regulations as well
as other early childhood programs including child care and head start. Located regional office
may have statewide travel but at minimum multiple county travel on routine basis is to be
expected

Covansys/CFO

Primary Responsibilities:
Provide leadership and management over finances. Provides strategic recommendations to other
members of the management team. Overseas all financial reporting. Track financial objectives
and budgets. Advise long-term financial planning. Establish and develop relations with all
stakeholders.

Occupational Therapist (OTR)

PRIMARY RESPONSIBILITIES:

Staff Occupational Therapist (OTR) will coordinate occupational therapy with other medical and
rehabilitation functions. Designs and implements occupational therapy programs for children
aged 0-35 months with developmental delay or disabilities. Interprets physician prescriptions,
evaluates client’s physical status, and assists child and family in achieving maximum
performance in activities related to self-care, play, and development. Treats children using
standard occupational therapy practices. Revises occupational therapy treatment program in
relation to the child’s progress, documents progress as per state standard, and instructs the child
and/or caregivers in therapeutic procedures.

WORKING RELATIONSHIPS

1. Reports to
The Staff Occupational Therapist (OTR) reports to Convansys (Central Finance
Office) and the Region IV Birth to Three Regional Administrative Unit.

2. Interrelationships
The staff occupational therapist works with other occupational therapy personnel,
physical therapy, speech therapy, nursing personnel, and any other service
personnel as needed as specified on the Individualized Family Service Plans.

RESPONSIBILITY AND AUTHORITY

Essential Duties & Responsibilities

● Adheres to all WV Department of Health and Human Resources Early
Intervention guidelines
 ● Participates in the planning and implementation of a comprehensive and
developmentally appropriate program for children with special needs and their
families.
● Participates as an evaluator and member of a multidisciplinary team that
determines eligibility for Early Intervention (EI) services. Supports the child and
family through the evaluation process.
● Administers, interprets, and shares results from occupational therapy assessments.
● Participates in the development of the Individualized Family Support Plan (IFSP)
with the family and other team members.
● As part of an IFSP team, helps families develop outcomes that are functional and
based on children’s and families’ needs and family-identified priorities.
● Pre-plans and debriefs with teammates in order to effectively coach families
through routine-based activities which incorporate communication skills, motor
skills (gross/fine), adaptive skills, cognitive skills, and social emotional/personal
social skills, utilizing a Primary Service Provider model.
● Provides consultative services to parents and other team members; interprets and
applies occupational therapy techniques; ensures proper follow through and
competence with techniques using a coaching approach.
● Provides ongoing monitoring of the child and family’s needs, concerns, and
strengths and assists with linking the child and family to appropriate resources as
needed.
● Establishes and maintains cooperative and collaborative relationships with
families and community agencies, public and private.
● Maintain billable hours as outlined by West Virginia Department of Health and
Human Resources and keeps participant records in accordance to Federal and
State requirements.
● Attends, facilitates, and participates in staff and team meetings.
● Provides services within natural environments (e.g. home, day care and
community).
● Attends and participates in transition meetings.
● Coordinate closely with the WV Birth to Three Regional Administrative Unit

Other Responsibilities
● Serves as the supervisor for students and/or volunteers within the program.
● Assists in maintaining a clean, hygienic, safe and “childproof” environment.
● Reports any safety concerns to the Regional Administrative Unit.
● Participates in training sessions and continuing education.
● Participates in and/or coordinates WV Birth to Three events (such as program
activities, community fairs, fundraising, etc.), as requested.
QUALIFICATIONS:

● Graduation from ACOTE accredited program with a masters or Master’s degree in

Occupational Therapy (MOT).
● Current registration with the National Board of Certification of Occupational Therapy.
● Registered and licensed as an Occupational Therapist by the West Virginia Board of
Occupational Therapy.
● Current First Aid and CPR certification

Services and Scope of Practice

● About Our Program and Scope of Practice:
Our program aims to provide early intervention occupational therapy services in the home and
the community. Get up and Grow OTs are highly qualified to treat children from 0 to 35 months
that have a wide range of developmental delays and physical disabilities. The treatment sessions
occur in the client’s natural environment, such as their home or in the community. We also will
provide in-depth parent/caregiver education in order to promote service carryover.

● Services Provided:
○ Get up and Grow OTs administer comprehensive evaluations, create family
centered treatment plans, collaborate to make attainable client goals, and
administer skilled, evidence based interventions focused on increasing the client’s
participation.
○ Help to create and provide services related to Individualized Family Service Plans
(IFSP) that will describe the real-life outcomes wanted for the child and family.
The IFSP lists how, where, and when your family will work with the
Occupational Therapists to reach those outcomes.
○ Get Up and Grow services include but are not limited to:
● Fine motor and gross motor interventions
● Sensory integration
● Improving flexibility, balance, and coordination
● Building muscle strength and endurance
● Oral motor skills intervention
● Family and caregiver education
● Promote developmental milestone progression
● Refer to other professionals
● Play based interventions
● Communication skills
● Target Population:
○ Children aged 0-35 months who have a confirmed medical condition that is
expected to lead to a developmental delay
○ Children aged 0-35 months who have a significant delay in one or more areas of
development:
■ Physical development, such as vision, hearing, movement and health
■ Adaptive or self help skills, such as feeding and dressing
■ Cognitive skills, such as thinking, learning, and reasoning
■ Social-emotional development, such as getting along with others,
expressing feelings, developing relationships
■ Communication skills, such as pointing, understanding your words,
expressing thoughts

Goals and Objectives

● Goals:
○ Strengthen and sustain partnerships with other community organizations in the
area of child care and child services
○ To consistently provide services to clients of all diagnoses aged 0-35 months
while remaining client and family-centered.
● Objectives
○ Create at least three new relationships, including connections, for the
advancement of care and services available and provided to children with/without
disabilities within 6 months
○ 75% of parents of Get up and Grow clients will report increased satisfaction with
the child’s and parent’s participation after 8 weeks of receiving skilled
occupational therapy services.
○ 75% of parents of Get up and Grow clients will report increased satisfaction in the
knowledge and skills related to their child’s development after 8 weeks of
receiving skilled occupational therapy services.
 Budget

● Building and Land cost: $0

○ Office space housed in owner’s finished basement
● Funding: Paid upfront by owners from personal money
● Business license LLC: $150 to start, $25 every year to file annual report
● Practice license: $300
● Liability insurance: $1-3M coverage ( $300 per year )

Office Costs

Ipad Air 256 GB (2) $1,558

Desktop Computer (2) $1,098

Filing Cabinet (2) $380

Wall Shelving/Storage $800

Desk (2) $655.48

Desk Chair (2) $139.98

Office Supplies (pens, paper, ink, etc.) $250

Printer $219

Total Cost: $5,100.46

Marketing Costs
 Flyers and Brochures $150

Business Cards $100

Promotional Materials (pens, notepads, $150

etc.)

Website $480

Social Media Ads $300

Total Cost: $1,180

Clinical Expenses

Toys (blocks, puzzles, etc.) $250

Therapy Supplies (stability ball, $250

foldable mat, etc.)

Cleaning Supplies (hand sanitizer, clorox $150

wipes, etc.)

Documentation Software (Fusion) $1,176 per year

Total Cost: $1,826

Assessments and Evaluations

Pediatric Evaluation of Disability $117.30

Inventory
 Peabody Developmental Motor Scales $585.30
(PBMS-2) Complete Kit

Bruininks-Oseretsky Test of Motor $981.00

Proficiency (BOT-2) Complete Kit

The Short Child Occupational Profile $40

(SCOPE)

Infant Toddler Sensory Profile $256.25

Ages & Stages Questionnaires®, Third $295

Edition (ASQ®-3)

Developmental Assessment of Young $370.30

Children (DAYC 2)

Total: $2645.15

Administration Costs

Business License $150

OT License (2) $300

Liability insurance $300 ($1-3 million in coverage)

Total Cost $750

Staff Salaries

OTR/L Sarah $86,400

OTR/L Hannah $86,400

 Total Cost: $172,800

Billable Units

Productivity 60%

Units Per Day 24

Units Per Week 120

Units Per Year 5,760

Billing per Visit

Visits Per Day, Per Therapist 6

Price Per Visit $120

Billing Per Day $720

Billing Per Week $3,600

Billing Per Year, Per Therapist $172,800

Overall Billing Per Year $345,600

Capital Expenses

Item Cost Photo Purchased From

 Ipad Air 256 GB $1,558 Apple
(2)

Desktop $1,098 Best Buy

Computer (2)

Desk (2) $655.48 Office Depot

Documentation $1,176 (per year) Fusion

Software

Peabody $585.30 Pearson

Developmental Assessments
Motor Scales
(PBMS-2)
Complete Kit

Bruininks- $981.00 Pearson

Oseretsky Test of Assessments
Motor Proficiency
(BOT-2) Complete
Kit

Wall $800 Furniture Cart

Shelving/Storage
 Total Cost: $6,853.78

Yearly Expenses

Documentation Software $1,176 (per year)

Liability Insurance $300

Business LLC License $25

Office Supplies (ink, paper, etc.) $500

Cleaning Supplies $300

Total Yearly Expenses $2,301

 Marketing

Logo

Business Cards
Logo for Promotional Materials (pens, pencils, notepads, etc.)
T-Shirts

Radio Ad
“Is your child falling behind developmentally, or is your child diagnosed with a developmental
delay or disability? If so, Get Up & Grow Occupational Therapy can help! Get up and Grow OTs
are highly qualified to treat children from 0 to 36 months that have a wide range of
developmental delays and physical disabilities. Under West Virginia legislature, early
intervention services are FREE of charge to any child who is eligible. Get Up & Grow
Occupational Therapy serves the Lincoln County area, and is based in Hamlin WV. By
supporting both the child and caregivers, Get Up & Grow strives to ensure that children and their
families can achieve maximum participation in all areas of their lives, specifically in their homes
and communities. Ask your child’s health care provider about a referral to receive occupational
therapy services. Call (304)-226-GROW (4769). That’s (304)-226-GROW (4769).”

Email to Physicians
Email Address: GetupandgrowOT@gmail.com

Hello (Name of physician)

 Get Up and Grow is a new Birth to Three provider that offers skilled occupational
therapy services in the Lincoln County area. Our staff consists of highly trained licensed OTs
that have vast experience working with children 0 to 36 months with a wide array of disabilities
and diagnosis. As West Virginia University graduates, our OTs are motivated to provide the
highest quality of care to fellow WV children and families.

Therapy Services Include:

● Comprehensive evaluations
● Create family centered treatment plans
● Collaborate to make attainable client goals
● Help to create and provide services related to Individualized Family Service Plans
(IFSP) that will describe the real-life outcomes wanted for the child and family.
● Specific Interventions Provided:
● Fine motor and gross motor interventions
● Sensory integration
● Improving flexibility, balance, and coordination
● Building muscle strength and endurance
● Oral motor skills intervention
● Family and caregiver education
● Promote developmental milestone progression

Please consider referring patients to Get Up and Grow who may benefit from our services.
Thank you,
Sarrah Coddington OTR/L
Hannah Linville OTR/L
Facebook Page
Floor Plan
 Revenue

Billable Units

Productivity 60%

Units Per Day 24

Units Per Week 120

Units Per Year 5,760

Staff Salaries

OTR/L Sarah $86,400

OTR/L Hannah $86,400

Total Cost: $172,800

 Program Evaluation
Patient Satisfaction survey: Get Up and Grow Caregiver Satisfaction
Employee Satisfaction survey: Employee Satisfaction Survey
Employee Evaluation form: Occupational Therapist Evaluation
Standardized Assessments: Peabody Developmental Motor Scales (PBMS-2), Bruininks-
Oseretsky Test of Motor Proficiency (BOT-2)

Objectives Indicator Goal Actual Conclusion/Recommendations

Increase community # new Increase by 3

partnerships partnerships each within 6 months
year

Increase parent/guardian Get Up & Grow 75% of

satisfaction with child’s Caregiver parents/guardians
participation Satisfaction will report at
least a 4/5 overall
Survey
satisfaction in 8
weeks

Increase parent/guardian Get Up & Grow 75% of

satisfaction with their Caregiver parents/guardians
knowledge of child’s skills Satisfaction will report at
and development least a 4/5 overall
Survey
satisfaction in 8
weeks

Increase employee Score from 100% of

satisfaction survey employees will
report at least 4/5
overall
satisfaction in 12
weeks

Get Up & Grow Caregiver Satisfaction Survey

Satisfaction

Thinking about your child's sessions on a scale of 1 to 5 (1 being very unsatisfied and 5 being
very satisfied), how would you rate:
The Occupational Therapy Service your child is receiving:

How prepared the OT was for the session:

How well he/she understood your concerns:

His/her thoroughness and competence:

Dedication and focus on achieving the goals set forth in my child's program:

Knowledge
Thinking about your child's sessions on a scale of 1 to 5 (1 being very unsatisfied and 5 being
very satisfied), how would you rate:

The consistency of information you received:

How often he/she provides me with information on my child’s progress:

How often you use the information provided/taught to you:

How much information you have learned regarding your child’s skills and development:

Occupational Therapist Evaluation

Essential Function Sources of Actual Rating

Measurement Performance

Thoroughness and Patient Satisfaction

competence of Score
services provided
 Dedication and focus Patient Satisfaction
on achieving the goals Score
set forth

Preparedness for Patient Satisfaction

sessions Score

Listened to Patient Satisfaction

patient/caregiver Score
concerns

Provides consistent Patient Satisfaction

information Score

Occupational Therapist Evaluation Cont.

SELF ASSESSMENT TOOL RATING SCALE

https://drive.google.com/open?id=1rBb4Qf5uq1zhxLdJVDBics09XfIzdrJR

Employee Satisfaction Survey

Thinking about your job satisfaction, on a scale of 1 to 5 (1 being the lowest and 5 being the
highest) how would you rate:

How much you find your work meaningful:

How high do you rate your work-life balance:

How much you are inspired by the mission of your company:

How much you feel valued:

How much you feel there is a scope for professional growth:

How much your team inspires you to do your best work:

How stressful is your work is:
*For this question only: ‘1’ is the highest amount of stress and ‘5’ is the lowest amount of stress

Documentation
WV BTT Documentation and Billing Forms

Service Billing Form:

OT Eval:
Assistive Tech Order Form:
Assistive Tech Billing:
BTT Request Forms:
 Policy and Procedure

Administrative Policy:
1. Emergency Protocol
2. Infection Control
3. Dress Code
4. Disciplinary Action

Clinical Policy and Procedure

1. Documentation
2. Continuing education
3. Confidentiality
4. Attendance

I, _________________________________ have read and understand the policies and procedures

within the manual.

Date: ______________________
Administrative Policy and Procedure 1 - Emergency Protocol

While in contact with any Get Up and Grow clients follow the following procedures:
1. Mandatory Reporter
○ According to West Virginia Code 49-2-803
■ Any medical, dental, or mental health professional, Christian Science
practitioner, religious healer, school teacher or other school personnel,
social service worker, child care or foster care worker, emergency medical
services personnel, peace officer or law-enforcement official, humane
officer, member of the clergy, circuit court judge, family court judge,
employee of the Division of Juvenile Services, magistrate, youth camp
administrator or counselor, employee, coach or volunteer of an entity that
provides organized activities for children, or commercial film or
photographic print processor who has reasonable cause to suspect that a
child is neglected or abused, including sexual abuse or sexual assault, or
observes the child being subjected to conditions that are likely to result in
abuse or neglect shall immediately, and not more than 24 hours after
suspecting this abuse or neglect, report the circumstances to the
Department of Health and Human Resources. In any case where the
reporter believes that the child suffered serious physical abuse or sexual
abuse or sexual assault, the reporter shall also immediately report to the
State Police and any law-enforcement agency having jurisdiction to
investigate the complaint. Any person required to report under this article
who is a member of the staff or volunteer of a public or private institution,
school, entity that provides organized activities for children, facility, or
agency shall also immediately notify the person in charge of the
institution, school, entity that provides organized activities for children,
facility, or agency, or a designated agent thereof, who may supplement the
report or cause an additional report to be made: Provided, That notifying a
person in charge, supervisor, or superior does not exempt a person from
his or her mandate to report suspected abuse or neglect.
2. Permission to Leave Contact with Client
○ Get Up and Grow employees may use their best judgement to determine whether
their safety is in immediate danger.
○ Get Up and Grow employees may terminate a session with a client if they believe
they are in danger.
 ○ Immediate threat or danger is present to employees or clients, Get Up and Grow
employees are required to file a report with the local police

Administrative Policy and Procedure 2 - Infection Control

1. Criminal Background Check

a. Within the last year
2. FBI Clearance/Fingerprinting
a. Within the last year
3. Child Abuse Clearence
a. Within the last year
4. 10 panel drug screen passed within 2 weeks of beginning the job
a. Randomized test may be conducted to staff at any time
5. 2 Step TB test
a. Within the last year
b. Will be updated yearly with 1 step TB test
6. Influenza shot
a. Required each year

Contact Precautions
1. Hand washing
a. Perform hand hygiene before and after contact with each client. Employees are to
use soap and water when hands are visibly contaminated.
2. Contact precautions
a. Should be utilized when direct or indirect contact with contaminated body fluids,
equipment, or the environment is anticipated
b. Wear gloves when in contact with patient or patient’s belongings when necessary
or upon request
3. Equipment
a. All equipment is to be sanitized before and after each use
i. Toys /supplies that are owned by the client do not need to be sanitized

ASSUMPTION OF RISK AND RELEASE

I recognize the risk of illness, injury, or infections associated with activities in a
home/community health care setting and voluntarily assume all such risk. I release Get Up and
Grow and subsidiaries from any claims or liability for any illness, injury, or infections arising
from or related to my activities at Get Up and Grow. I authorize Get Up and Grow to administer,
at my expense, any emergency care that is deemed necessary in care of illness, injury, or
infection.
Administrative Policy and Procedure 3 - Dress Code

All Get Up and Grow staff must follow dress code as outlined or they will be penalized and not
permitted to provide any patient care until they have changed into appropriate clothing.
1. Scrubs of their choice
a. Exposure of cleavage, butt, stomach and back are not acceptable
b. Printed and colored scrubs are permitted
2. Shoes
a. Must be closed toe shoes
b. Socks must be worn
3. Name badge
a. Get Up and Grow badge with proper credentials should be worn at all times
b. This is for identification
c. If name badge is lost or stolen report immediately to your manager
4. Jewelry
a. Must be appropriate for work
b. No more than two ear piercings should be displayed
c. Assure jewelry does not distract or become a safety problem when treating
patients
5. Grooming
a. Beards
i. Must be kept clean and tidy
b. Hair
i. Should be clean
ii. Should be styled in a way that does not interfere with patient treatment
c. Finger nails
i. To reduce the risk of infections, staff must keep fingernails clean and
fingertip length
6. Perfume and cologne
a. These products should not be used to protect patients who may be sensitive or
allergic to smells
7. Hat/Head coverings
a. Hats are not permitted while treating patients
b. Head coverings, for cultural, religious or medical reasons are permitted by staff
8. Tattoos
a. Tattoos must be covered during all times while treating patients

Administrative Policy and Procedure 4 - Disciplinary Action

Attendance
1. No call, no-show
a. An incident of no call, no show occurs when an employee fails to come to work at
the start of a scheduled work day or fails to show up to a client appointment
b. Employees who do not report to work consecutively will be considered to have
their employment terminated
c. Repetitive but non-consecutive incidents of no call-no show will result in
disciplinary action
2. Tardiness
a. All Get Up and Grow employees are expected to report for work on time. Any
employee who fails to report to work at specified starting times and session times
will be considered tardy
i. A ten minute grace period will apply before an employee is considered
tardy
b. Employees MUST notify clients if they will be more than 10 minutes late to a
session
c. Tardiness is excessive when it occurs and is unreported more than three times in a
given pay period for two or more consecutive pay periods
d. Excessive tardiness may be grounds for disciplinary action, depending upon its
severity, frequency, and impact on work performance

Clinical Policy and Procedure 1 - Documentation

All documentation must be done in accordance to WV Birth to Three policy

The style of documentation that will be recorded will include:

● Evaluations
○ Full intake
■ Medical History, etc.
○ At least one standardized evaluation
○ Goals developed with patient and family
○ Copy must be given to client’s caregiver
● Daily Notes
○ Must be completed prior to leaving contact with client
○ Copy must be given to client’s caregiver
● Discharge
○ Progress towards goals
○ Discharge recommendations
*All documentation should be held in the strictest confidentiality

Clinical Policy and Procedure 2 - Continuing Education

It is required of all therapy staff to complete 12 hours of continuing education a year.

The year begins and ends on the date of your licensure renewal.
● Therapy staff may use their own discretion when determining what continuing education
to complete
● Therapy staff is required to pay for their continuing education
● Continuing your education helps provide a way of improving your professional
competence with the outcome of improved patient care

Clinical Policy and Procedure 3 - Confidentiality

All staff must ensure confidentiality of our patients and their families
● All personal and medical information obtained about them will be held in strict
confidence.
Confidentiality:
● All records, conversations and services provided will adhere to confidentiality practices
● Written information regarding a patient, client, staff of their families may be released to
external parties only after obtaining written permission from the individual or their family
if they are personally unable to do so.
○ An exception exists only in the events data is subpoenaed by the proceedings
● All files must be returned and locked in appropriate file cabinets at the end of each day
● Should a crisis arise immediately contact your manager whenever possible prior to
releasing pertinent information to the police, Child Protection Services, etc.
○ Mandatory reporting is required of suspected abuse, or life threatening situations

Disciplinary Action
● Any staff who have violated a patient, client, or staff members right to confidentiality
will receive disciplinary action up to and including termination of employment
● Any time an extreme circumstance takes place Get Up and Grow may choose to impose
the most severe penalty (including legal action) based upon the degree of damage to the
patient, client, staff member, etc.

Clinical Policy and Procedure 4 - Patient Attendance

Employees should make patients aware of patient attendance policy

 ● Patient success in birth to three is a direct result of the regular attendance of and
participation in your child’s therapy program, communicating openly with your therapist
● We will do our best to work around schedules to accommodate the patient to the best of
our ability
● If the patient falls ill during the program please inform the therapist as soon as possible
and we will reschedule that session for a later date

Get Up and Grow policy states that patients may be discharged from services for any of the
following reasons:
● 5 consecutive missed or cancelled appointments within 1 month
● Repeated failure to notify the therapist of cancellation of sessions and/or tardiness for
sessions

If the above events occur:

● The patient may be discharged
● The patient’s physician and insurance carrier will be informed
● If the patient is discharged because of attendance problems:
○ Re-referral for services will require approval by the treating therapist and a new
physician referral

Cancellations
● A minimum of a 12 hour notice must be given for any cancellation
○ Emergencies are an exception to this notice
● If you will be 10 minutes or more late, you may not be able to be seen at that time or
recieve a full session

I, ____________________________, have read the above Attendance Policy and understand that
my cooperation and active participation directly related to the success of my child’s birth to three
occupational therapy program.

_________________________________ ________________________
Patient’s Signature Date
 Quality Assurance

Patient Satisfaction Survey Results:

The Occupational Therapy Service your child is receiving:

● Scores:
○ 1: 3 people
○ 2: 7 people
○ 3: 18 people
○ 4 or 5: 22 people
● Average Score: 3.62

How prepared the OT was for the session:

● Scores
○ 1: 15 people
○ 2: 9 people
○ 3: 6 people
○ 4 or 5: 20 people
● Average Score: 3.02

How well he/she understood your concerns:

● Scores
○ 1: 2 people
○ 2: 6 people
○ 3: 32 people
○ 4 or 5: 10 people
● Average Score: 3.2

His/her thoroughness and competence:

● Scores
○ 1: 34 people
○ 2: 15 people
○ 3: 1 person
○ 4 or 5: 0 people
● Average Score: 1.34

Dedication and focus on achieving the goals set forth in my child's program:
● Scores
○ 1: 7 people
 ○ 2: 18 people
○ 3: 20 people
○ 4 or 5: 5 people
● Average Score: 2.56

Knowledge
Thinking about your child's sessions on a scale of 1 to 5 (1 being very unsatisfied and 5 being
very satisfied), how would you rate:

The consistency of information you received:

● Scores:
○ 1: 3 people
○ 2: 7 people
○ 3: 18 people
○ 4 or 5: 22 people
● Average Score: 3.62

How often he/she provides me with information on my child’s progress:

● Scores
○ 1: 15 people
○ 2: 9 people
○ 3: 6 people
○ 4 or 5: 20 people
● Average Score: 3.02

How often you use the information provided/taught to you:

● Scores
○ 1: 2 people
○ 2: 6 people
○ 3: 32 people
○ 4 or 5: 10 people
● Average Score: 3.2

How much information you have learned regarding your child’s skills and development:
● Scores
○ 1: 34 people
○ 2: 15 people
○ 3: 1 person
○ 4 or 5: 0 people
 ● Average Score: 1.32

Comments made:

“Therapy was great when I was able to be seen in a timely manner. The therapist was always
running 15-20 minutes behind!”

“The therapist was professional and treated me and my child with respect.”

“I just love Get Up and Grow therapy services they are amazing!!”

Changes We Would Make:

● Increase preparedness
○ We were given a score of 3.02 in this section
○ Therapists will need to have a plan set in place prior to starting sessions
○ We were also given feedback that the therapist was always 15-20 minutes behind
■ We will have a meeting with the therapist to get their side
■ Disciplinary action may need to take place
● Increase empathy
○ We were given a score of 3.4 in this section
○ Caregivers reported they didn’t think therapists understood their concerns
○ We will instruct therapists that they need to ask the parents and make sure all of
their concerns have been addressed
● Increase caregiver education
○ We had unacceptable scores in the following areas:
■ Thoughtfulness and competence: 1.34
■ Provides information on child’s progress: 3.02
■ Use information provided to you: 3.2
■ Learned about child’s skills and development: 1.32
○ We will have a meeting with therapists and discuss ways to increase the quality
and quantity of caregiver education
■ Giver caregivers points about child’s progress after each session
■ Give caregivers clearly stated HEP programs, explain the activities,
provide visual demonstration, and ask the caregiver to demonstrate
○ We will be sure to thoroughly explain our intervention methods being respectful
to health literacy of caregivers
■ Hopefully this will remediate problem regarding caregivers perception of
our competency
 Concept Map

Regulated By

West Virginia Birth to Three is regulated by Individuals with Disabilities Education Act (IDEA)
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