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Volume 11, No. 11F — November 2012

Occupational Therapists & COTAs
NEWS-Line for

News, Information and Career Opportunities

Greater Parental Stress Linked to Children’s Obesity, Fast Food Use, Reduced Activity Is Declining Medical Imaging Use Driving Up Hospital Stays and Medical Costs?

Certified Occupational Therapy Assistant

QA Stacia Raftovich,

Researchers Map Strategy for “Choosing Wisely” on Low-Value Healthcare Services

at Theraplay in West Chester, Pennsylvania
Conferences & Educational Opportunities • Job Opportunities

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& QA with Stacia Raftovich,

Certified Occupational Therapy Assistant at Theraplay in West Chester, Pennsylvania

Stacia Raftovich is a certified occupational therapy assistant working in pediatrics at Theraplay. She has an associate’s degree as a COTA from Delaware Technical Community College in Wilmington, Delaware, and is obtaining a bachelor’s degree in health science at Philadelphia University in Philadelphia, Pennsylvania. Stacia is back in school and on track to further her career as an occupational therapist. She says, “I am part of one of the most fun, enjoyable, challenging and fast-paced professions…I wouldn’t trade it for the world.”

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7 Occupational Therapy News
Greater Parental Stress Linked to Children’s Obesity, Fast Food Use, Reduced Activity Is Declining Medical Imaging Use Driving Up Hospital Stays and Medical Costs? Researchers Map Strategy for “Choosing Wisely” on LowValue Healthcare Services

10 Conferences & Educational Opportunities

12 Job Opportunities
12. Faculty, National and Pennsylvania 13. Virginia, Florida and Michigan 14. Michigan and Washington 2. California

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Q: Can you describe your educational background? A: I currently hold an AD as a Certified Occupational Therapy Assistant. This past spring, I enrolled in an accelerated program at Philadelphia University to obtain a bachelor’s degree in health science with the ultimate goal of receiving my master’s in occupational therapy. I have also attended a conference for The Alert Program in regard to sensory regulation, as well as Interactive Metronome, which I am now certified for in clinic and home unit use. Q: What motivated you to enter occupational therapy? A: I have always had an interest in working with individuals with special needs. In high school I completed volunteer hours at A.I. DuPont Hospital for Children and various special needs programs at local elementary and high schools. These experiences led me to apply for and ultimately receive the role of my high school’s Blue*Gold Ambassador my junior and senior years. Blue*Gold is an organization in Delaware that pairs local high school students together with “buddies” who have varied forms of intellectual disabilities. I coveted my role greatly and used the position to raise awareness within my school and community. I was always torn between the professions of special education and occupational therapy. The summer before my freshman year of college I took a one-credit course, which broke down the different allied health professions that Del

Certified Occupational Therapy Assistant

& QA with Stacia Raftovich,

at Theraplay in West Chester, Pennsylvania

Stacia Raftovich is a certified occupational therapy assistant working in pediatrics at Theraplay. She has an associate’s degree as a COTA from Delaware Technical Community College in Wilmington, Delaware, and is obtaining a bachelor’s degree in health science at Philadelphia University in Philadelphia, Pennsylvania. Stacia is back in school and on track to further her career as an occupational therapist. She says, “I am part of one of the most fun, enjoyable, challenging and fast-paced professions…I wouldn’t trade it for the world.”


NEWS-Line for Occupational Therapists & COTAs • November 2012 Feature

Tech offered. Occupational therapy just happened to be one of the highlighted professions, and after watching the short clip on the program I was sold. OT offers everything I always looked for in a career. I am able to work hands-on with individuals to make their every day lives just a little simpler. It is by far a rewarding career that makes me feel very beneficial to others. Q: When and how did you start at Theraplay? A: I was initially introduced to Theraplay, Inc. during my second and final full-time clinical rotation for my COTA program. I was assigned to the West Chester office for three months. After graduation I took my entrance exam and started one month after splitting my time between the West Chester and Broomall offices parttime. You could say once I started I never left! Q: Typically, what are your dayto-day responsibilities as a COTA? A: On a typical day I can treat up to eight patients with a full schedule. In my down time at the office, I assist with department projects, and keep up with the cleanliness and organization of the treatment spaces. Recently, I have taken on the role of Volunteer Coordinator at the West Chester office. This role has given me great responsibility in overseeing the volunteers and interns and assigning their schedules, and contacting therapists to observe for school and personal interests. Q: What type of patients/diagnoses do you encounter most frequently? A: Our company serves children ranging in ages birth to 21 with a variety of diagnoses. Personally, I tend to work more regularly with children ranging in ages from 3 to 14. During my time here at Theraplay I have worked closely with patients with diagnoses of autism, cerebral palsy, Down syndrome, sensory regulation and developmental delay. A: I would say the greatest challenge I face in my job is ensuring I have confidence in my abilities and myself. Many times I still tend to second-guess myself with new or difficult situations, even though I have had proper experience and education. I always want to make sure I am providing the best care possible, which can sometimes lead to extra pressure from me. I must remember I am constantly learning and that each and every day may lead to new learning experiences, including errors from which to grow. Q: What do you love about your job?

Q: Are there other areas of interest for you as a COTA, either A: I truly love the day-to-day interclinically or educationally, that actions I have not only with my you plan to pursue? patients, but also my colleagues and local practitioners. I grow A: When I first graduated a few and learn from everyone I come years ago, I was still getting over in contact with in one way or the accomplishment of graduation another because each person and starting a new career. However, teaches me something different. as time went on I began to get the My patients teach me how to have “itch” to look into becoming a fullpatience, be caring and ultimately fledged occupational therapist. treat them, and my colleagues After getting my first year here at teach me old and new strategies Theraplay under my belt, I looked beneficial for clinical use, how to into various options within the area. I interact with families and difficult made the exciting decision to return situations, and how to believe to school to obtain my bachelor’s in my abilities and in myself. degree in health sciences, followed Ultimately, I love the triumphs by my ultimate goal of receiving my and the changes my patients master’s degree in occupational show, from as big as writing a therapy. I have also shared my inter- paragraph with no errors to as ests in assisting during marketing simple as lying on their belly on presentations to review various diag- a scooter for a few seconds. The noses and developmental levels, upsets and the cries can get to and will begin to brainstorm ideas you sometimes, but the rewards working with various NICU departand the achievements far exceed ments to provide early support. any negatives. Q: What are the greatest challenges you face in your job?

Q: Are you currently involved with any research projects?


A: The OT team and I are regularly completing Evidence-Based Practice article reviews, training updates and new treatment ideas. I am also in talks with our company’s marketing director to complete research on the benefit and need for education for parents and families with children in the NICU. therapy accomplishments was with a young boy whom I had been working closely with over a couple months. His goal was to propel a scooter on his stomach with no help. The trouble was he was afraid to even sit on the scooter. After months, little by little, we slowly were able to gradually increase his acceptance of Q: Do you feel the role of a COTA the scooter in general. I can sit has changed in recent years? here today and say that he is now able to stay on his stomach A: Yes. It is now common for a on the scooter and propel himCOTA to take on more responsiself to complete puzzles while bilities within his/her work facility moving around. Although it took and to complete various trainings several months to achieve, the and certifications. pride I felt in him was enormous. Sadly, as much as we would love Q: What do you feel is of the for our patients to stay around greatest concern to your profor a long time to continue to see fession today? their progression, it is such a fulfilling feeling to see and hear A: I believe it may be with the parent’s reactions to their time need for individuals working within at school and home and how Skilled Nursing Facilities. I remem- much growth they have seen. ber back to one of my placeTheir emotions remind you on ments in school, working with your worst days how lucky we the geriatric population and my are to be able to have a part in hesitations of whether it would be our patient’s lives and the differthe right place for me. Ultimately, ences we can make. it was not my best fit but I was truly, pleasantly surprised at how Q: What is the most important comfortable I was and enjoyed thing you’ve learned over the the atmosphere. Although Skilled course of your career? Nursing Facilities may not be my overall favored places to work, it is A: Over the course of my short definitely one of the most reward- career as a Certified Occupational ing and could use more skilled Therapy Assistant I have learned individuals. more than I ever could have imagined. However, I continue to learn Q: What is the most fulfilling confidence and patience on the part of your job? job. Confidence in my abilities of treating without direct superviA: The most rewarding part of sion, as it was during school, and my job is truly working hand confidence in my explanations and hand with the children and and treatment recommendations seeing their accomplishments, to families. Patience is one of the big or small. One of my first true greatest things a therapist can learn because at the end of the day when you are having one of your toughest sessions and you just want to give up, patience is what keeps you going. I believe it grounds you to take a moment to stop and take in the situation and plan out the best course of action. Also, when you look at the big picture, nine times out of 10 the patient having a difficult time doesn’t have full control of their emotions and needs that little extra help. Q: How has working in OT allowed you to grow professionally? A: Being part of this profession has allowed me to grow professionally in more ways than I could have hoped. I am part of a very small number of individuals fortunate enough to come directly out of college into a career, and land a position in which I have so many opportunities to grow and succeed in. Q: What advice do you have for others thinking of entering pediatric occupational therapy? A: If I had a chance to offer advice to others thinking of entering the field, I would say it is truly an overwhelmingly rewarding career. It will not always be easy, and there will be days when you question your ability; however, if you take a step back and see all the good you can accomplish, the hard days will truly be far and few in between in the long run. I am part of one of the most fun, enjoyable, challenging and fast-paced professions, and yet I wouldn’t trade it for the world. F


NEWS-Line for Occupational Therapists & COTAs • November 2012 Feature


Greater Parental Stress Linked to Children’s Obesity, Fast Food Use, Reduced Activity

perceived parental stress may result in less supervision of children, who may then make unhealthy food and activity choices.

“Although multiple stressors can elicit PARENTS WITH A HIGHER givers who participated in telephone a ‘stressor pile-up,’ causing adverse NUMBER of stressors in their lives surveys in the 2006 Southeastern physical health in children, parent’s are more likely to have obese chilPennsylvania Household Health perception of their general stress dren, according to a new study by Survey/Community Health Database, level may be more important than the pediatric researchers. Furthermore, conducted in Philadelphia and actual stressors,” the authors write. when parents perceive themselves neighboring suburbs. The houseto be stressed, their children eat holds contained children aged 3 to Future research on child obesity fast food more often, compared to 17, among whom 25% were obese. should further examine other family children whose parents feel less Among the variables included were behaviors and community factors stressed. parental stressors, parent-perceived not available in the current study, stress, age, race, health quality and conclude the authors. In addition, “Stress in parents may be an imporgender of children, adult levels of “Clinical care, research and other tant risk factor for child obesity and education, BMI, gender, sleep qualprograms might reduce levels of related behaviors,” said Elizabeth ity, and outcomes such as child obechildhood obesity by developing Prout-Parks, MD, a physician nutrition sity, fast-food consumption, fruit and supportive measures to reduce stresspecialist at The Children’s Hospital vegetable consumption, and physical sors on parents,” said Prout-Parks. of Philadelphia, who led a study pub- activity. “Teaching alternative coping stratelished online in the November issue gies to parents might also help them of Pediatrics. “The severity and num- Of the measured stressors, singleto reduce their perceived stress.” ber of stressors are important.” parent households had the strongest relationship with child obesity, while Dr. Prout-Parks’ co-authors were Among the parental stressors assofinancial stress had the strongest Shiriki Kumanyika, PhD, MPH, from ciated with childhood obesity are relationship for a child not being the Center for Clinical Epidemiology poor physical and mental health, physically active. Unexpectedly, and Biostatistics at the University of financial strain, and leading a single- neither parent stressors nor parentparent household, said Prout-Parks. perceived stress was associated with Pennsylvania School of Medicine; Renee H. Moore, PhD, Center for Although previous researchers had decreased fruit and vegetable conWeight and Eating Disorders and found a connection between paren- sumption by their children. Center for Clinical Epidemiology tal stress and child obesity, the curand Biostatistics at Perelman School rent study covered a more diverse However, this study was the first of Medicine at the University of population, both ethnically and to find an association between Pennsylvania School of Medicine; socioeconomically, than did previous parent-perceived stress and more Nicolas Stettler, MD, MSCE, of studies. frequent fast-food consumption by children. Fast food, often containing Exponent, Inc.; Brian H. Wrotniak, PhD, Center for Weight and Eating The study team suggested that inter- high quantities of fat and sugar, is Disorders and the University of ventions aimed at reducing parental an important risk factor for obesity Buffalo; and Anne Kazak, PhD, stress and teaching coping skills and child health. The researchers may assist public health campaigns speculated that parents experiencing ABPP, of The Children’s Hospital of Philadelphia. in addressing childhood obesity. stress may buy more fast food for the family, to save time or reduce the The researchers analyzed self-report- demands of meal preparation. The Source: Children’s Hospital of ed data from 2,119 parents and care- authors also suggest that actual and Philadelphia



Is Declining Medical Imaging Use Driving Up Hospital Stays and Medical Costs?
A NEW REPORT by the Harvey L. Neiman Health Policy Institute shows that the length of the average hospital stay in the United States has increased at the same time as use of medical imaging scans has declined. It is unclear if the trends are related, but potentially important, as hospital admissions are among the largest, and fastest growing, healthcare costs. More research is needed to assess the potential negative impact of government and private insurer imaging reductions on overall medical costs and patient safety. “Lawmakers, regulators and medical professionals are making medical imaging policy decisions without fully understanding or examining their downstream effects—which may include an increase in hospital stays, associated costs and other adverse events. We need to examine imaging, as it relates to a patient’s overall continuum of care, to ensure that decision makers don’t create imaging cost reduction policies which paradoxically raise overall costs, create barriers to care, and ultimately harm patients,” said Richard Duszak, MD, chief executive officer and senior research fellow of the Harvey L. Neiman Health Policy Institute. Much of a building body of research regarding medical imaging focuses on declining costs and utilization of imaging. There is relatively little research focused on imaging as a component of overall patient care. For many serious indications, imaging scans have been shown to reduce the number of invasive surgeries, unnecessary hospital admissions and length of hospital stays. Rarer still is data on the effect of $6 billion in funding reductions for imaging diagnosis and treatment planning since 2006. The information that is available is not necessarily positive in terms of patient safety and access to care. This is the first policy brief produced by the Neiman Institute, which conducts and supports research regarding medical

imaging use, quality and safety metrics, and human resources as medicine moves toward nontraditional, value-based payment and delivery. The data gleaned from these efforts will serve as the basis for true, evidencebased medical imaging policy. “We need to take a hard look at the cost, access and quality and safety issues related to present government and private insurer medical imaging policies and find ways to maximize the value, role and efficiency of radiology as healthcare systems evolve. The Neiman Institute will provide much needed information to ensure that future imaging policies benefit patients and make efficient, effective use of healthcare resources,” said Duszak. For more information about HPI, visit Source: American College of Radiology (ACR)


NEWS-Line for Occupational Therapists & COTAs • November 2012 Feature


Researchers Map Strategy for “Choosing Wisely” on Low-Value Healthcare Services
CUTTING THE EXPENSES associated with “low-value” medical tests and treatments—such as unnecessary imaging tests and antibiotics for viral infections that won’t benefit from them—will require a multi-pronged plan targeting insurance companies, patients, and physicians, according to a JAMA Viewpoint article published by researchers from the Perelman School of Medicine at the University of Pennsylvania. These efforts transcend economic impact, however, and may also be essential for improving health care quality and patient safety. tual sense, but in the end failed to show a significant reduction in subsequent cardiac problems or healthcare spending. And other studies involving higher co-pays resulted in prescription-drug cost savings, but led to higher rates of emergency room visits and hospitalizations—so no money was saved overall.

while insurance benefits can be designed to help steer patients away from low-value care, in many cases patients will need help from their providers in determining which care falls into that category and why.” In addition, the authors recommend that the underlying financial incentives for clinicians to provide or prescribe certain tests and treatments should be connected to their value. This could disincentivize the use of low-value services that are aren’t backed by evidence showing that they are worth using, or that the benefits they offer outweigh the potential risks associated with their use. Currently, committees that create testing and treatment guidelines within the Centers for Medicare and Medicaid Services and other organizations are barred from including assessments of cost and value in their work, though this practice has become customary in parts of Europe. “The trouble with ‘choosing wisely’ is that it is not just hard for patients, it is also hard for physicians,” says senior author David Asch, MD, MBA, executive director of the Penn Medicine Center for Innovation. “If ‘choosing wisely’ were easy, we wouldn’t be in the mess we’re in right now.” But, as the authors point out, eliminating the use of low-value services is ultimately what the healthcare system must do in order to keep supporting the use of high-value, often lifesaving, services. Source: Perelman School of Medicine at the University of Pennsylvania

The Penn researchers suggest, however, that these “value-based” strategies could be designed more effectively in order to cut the use of low-value services or drugs. Bringing cost sharing strategies in line with evidence-based screening guidelines, for instance, might The piece follows last spring’s play a role in reducing expendilaunch of the “Choosing Wisely” tures. If prostate-specific antigen initiative, a project of the American testing—no longer supported by Board of Internal Medicine and the US Preventive Services Task Consumer Reports magazine. This Force—were no longer covered by public and physician education insurance plans and physicians campaign identifies procedures and were instead required to discuss tests that add little value and may be why the service may actually harm unnecessary or even cause harm. patients, they write, it would “send a The campaign encourages stakepowerful signal to patients, who may holders to improve consideration generally assume that all healthcare and discussion of the proper uses services provided are of high value.” of these services. “Incorporating insights from psySeveral seemingly promising strate- chology and behavioral economgies have been proposed to encour- ics that help reveal how patients age the use of high-value services make these decisions is also and discourage low-value services, important,” says lead author Kevin but they yielded mixed results. For Volpp, MD, PhD, director of Penn’s example, a study aimed at improvCenter for Health Incentives and ing medication adherence among Behavioral Economics and a profesheart attack patients by eliminating sor of Medicine and Health Care co-pays for medications such as Management at the Wharton School. statins appeared to make concep“That process is quite nuanced, and


Conferences and Educational Opportunities
9th Annual Upper Extremity Tutorial, Placing the Hand in Space: Reconstructive Surgery of the Shoulder, Elbow and Wrist. Sponsored by the Hand Rehabilitation Foundation. February 10-14, 2013 Viceroy Hotel, Snowmass, CO Phone: 610-768-5958 Fax: 610-768-8887 Email: [email protected] Web: 15th Annual Philadelphia Hand Surgery Symposium (Surgery and Rehabilitation of the Hand: With Emphasis on the Wrist). Sponsored by the Hand Rehabilitation Foundation. April 6-8, 2013 Sheraton Downtown Hotel, Philadelphia, PA Phone: 610-768-5958 Fax: 610-768-8887 Email: [email protected] Web:

Conferences & Educational Opportunities
2012 AOTA Specialty Conference - Stroke. Sponsored by the American Occupational Therapy Association. November 30–December 1, 2012 Baltimore, MD Phone: 301-652-2682 Fax: 301-652-7711 Web:

2013 NCAL Spring Conference. Sponsored by the National Center for Assisted Living. March 12-13, 2013 Westin Beach Resort & Spa, Fort Lauderdale, FL Phone: 202-842-4444 Fax: 202-842-3860 Web:

Assisted Living & Senior Housing Summit. Sponsored by Care Providers of Minnesota. August 21-22, 2013 Location TBA Phone: 952-854-2844 Fax: 952-854-6214 Email: [email protected] Web:

AAHS 2013 Annual Meeting. Sponsored by the American Association for Hand Surgery. January 9-13, 2013 Waldorf Astoria Naples Grand Hotel, Naples, FL Phone: 978-927-8330 Fax: 978-524-8890 Web:


Pediatric Upper Extremity PreCourse 2013 for Surgeons and Therapists. Sponsored by the Hand Rehabilitation Foundation. April 5, 2013 Sheraton Downtown Hotel, Philadelphia, PA 2013 Phone: 610-768-5958 NCHCFA 2013 Annual Convention. Fax: 610-768-8887 Email: [email protected] Sponsored by the North Carolina Health Web: Care Facilities Association. February 10-13, 2013 Greensboro, NC Phone: 919-782-3827 Web:



NEWS-Line for Occupational Therapists & COTAs • November 2012 Feature


Faculty, National and Pennsylvania


Job Opportunities

Occupational Therapists
for long-term relationship.
Premier Therapy Services, a recognized leader in senior care, seeks OTs for their in-house therapy programs. Centers located in: New Jersey, Connecticut, Massachusetts, Vermont, New Hampshire, Rhode Island, Maryland, Virginia, Washington. We offer competitive pay, comprehensive benefits, flexible scheduling and a flexible work schedule in a pleasant, professional environment. Quality patient care is our number one concern. Graduating students may apply. For consideration, please contact: Monica Labato, Recruitment Manager, Premier Therapy Services 201 South Main St, Building A Loft, Lambertville, NJ 08530 609-397-7200 (office) • 862-400-5494 (cell) 609-397-3278 (fax) Email: [email protected]

Care-driven program seeks


NEWS-Line for Occupational Therapists & COTAs • November 2012 Feature

Virginia, Florida and Michigan

Fairfax, Virginia

Ocoee, Florida

Occupational Therapist Home Health • PRN Per Diem
The Virginian, a Continuing Care Retirement Community, is seeking a well qualified experienced Home HealthCare OT to provide services on a PRN per diem basis. This is a unique opportunity to join a quality driven team providing excellent patient care. The selected OT will deliver home services ensuring individualized treatment of assigned patients and prioritize, plan, communicate with team members such as nurses, therapists, physicians and/or home care assistants. Candidate must have proven experience in Home HealthCare. Virginia OT license required. Rates are negotiable dependent upon experience. If interested in joining our team, please email resume to Lynn Rountree, Human Resources Director, at [email protected] or fax to 703-385-0161.

Pediatric Occupational Therapist
Immediate opportunity for energetic Pediatric OT in busy private practice. Enjoy full or part-time schedule, family atmosphere and nice working environment with private treatment room. MUST LOVE KIDS! For immediate consideration, please contact Sherri: [email protected] Phone: 407-295-2956 Fax: 407-295-5808 Tampa, Florida

The Virginian

9229 Arlington Blvd. Fairfax, VA 22031 Phone: 703-277-7245

Home Care
Full-time and per diem positions available in Florida for OT with home health experience. Email resume to Donna Russo at [email protected] or call 954-834-2222

Occupational Therapists

OccupatiOnal therapist
The Laurels of Coldwater, Michigan, currently has openings for OTs on a full-time and a PRN (weekends) basis. We are a progressive SNF/ Rehabilitation Center with an active medical staff specializing in short term rehab treating guests with a variety of diagnoses. QualiFicatiOns: Must be a graduate of a certified program, nationally certified, and eligible to practice in Michigan. Terrific opportunity for a recent grad or professional with limited SNF/LTC experience to join our team and work with this caseload. Laurel Health Care Company staffs our employees in house - not thru contract companies and offers a competitive compensation and benefits package. Qualified candidates should submit resume to or call: Matt Graeber, OTR/RSD Rehab Services Director

the laurels of coldwater

90 North Michigan Avenue, Coldwater, MI 49036

Phone: 517-279-9808 • Fax: 517-279-2578 Email: [email protected]


Michigan and Washington

Battle Creek, Michigan

Tacoma, Washington area

OccupatiOnal therapists
The Laurels of Bedford's Rehab Team is seeking OTR/Ls for PRN opportunities. We are looking for someone with experience in a sub-acute rehab; however, we will gladly train the right candidate. The candidate we are looking for, will have strong clinical skills, be organized, motivated and interested in joining a dynamic rehab team. We offer a pleasant working environment and competitive pay. We encourage and promote professional growth. If you are interested in joining our well-versed, experienced and energetic rehab team, please contact or submit your resume to: Rachel Pallett, Rehab Director [email protected]
270 N. Bedford Rd., Battle Creek, MI 49017 fax 269-968-8943

Immediate opportunity to work for award-winning MultiCare Health System in the beautiful Puget Sound region of WA State! MultiCare is in the top 2% in the nation for our EPIC electronic medical record, and in the top 5% in the country fiscally. Our CEO is one of 5 women RN’s in the country who run a health care system! She knows what great health care is about, and values our 10,000 employees with excellent working conditions and full benefits!

Full time - Home Health Occupational Therapist
Work in our well established Home Health department providing Occupational Therapy treatment to varying ages of outpatients with a variety of diagnoses, according to the principles and practices of evidence-based Occupational Therapy. Will maintain current and timely treatment documentation and charges for services using system-wide EPIC electronic medical records. Will consistently demonstrate and model behaviors consistent with MultiCare’s Behavioral Competencies of excellence, service, quality, respect, and kindness. The successful candidate will have a minimum of one year experience as an OT. Experience in Medicare Certified Home Health preferred. Position requires valid and current Washington State OT License. Must have valid WA State drivers license. Please contact senior recruiter, [email protected] for more information, or apply at

The LaureLs of Bedford
NEWS-Line for Occupational Therapists & COTAs • November 2012 Feature

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