CIVIL COVER SHEET
`(Rev. 10/20)
`JS 44
`The .18 44 civil cover sheet and the information contained herein neither replace nor supplement the filing and service of pleadings or other papers as required by law, except as
`provided by local rules of court. This form, approved by the Judicial Conference of the United States in September 1974, is required for the use of the Clerk of Court for the
`purpose of initiating the civil docket sheet.
`(SEElNh‘i’li’ti'tft’l'ONSON lem‘l’AGli' OF THIS FORM.)
`1. (a) PLAINTIFFS
`DE FENDANTS
`
`Andrea Summers
`
`The Children's Hospital of Philadelphia
`
`Philadelphia
`(b) County of Residence of First Listed Plaintin
`flz'X('1:'PTIN US. l’i’;1.i'N'l’Tl'"ll'(.‘A.’\‘l§S}
`
`County of Residence of First Listed Defendant
`(IN US. [’IAJNTH517 CASES ONLY)
`IN LAND CONDEMNATlON CASES, USE THE LOCATION OF
`THE TRACT OF LAND INVOLVED.
`
`NOTE:
`
`(C) Attomeys (I-l'mt Name. Address, and Telephone Number)
`Robert T Vance Jr. 100 South Broad Street. Suite 905,
`Philadelphia PA 19110 215 557 9550
`
`Altomeys (HKmier
`
`I]. BASIS OF JURISDICTION (Place an “X” in Uni.- Box Only)
`
`El | US Government
`Plaintiff
`
`ES Federal Question
`(US. Government Nor a flurry)
`
`[11. CITIZENSHIP 0F PRINCIPAL PARTIES {Place an "X" in One Buxfor I’lalnrifi'
`(For Diversity ( 'ases Only)
`and One Bax fiir Delis-Mani)
`DEF
`P'l‘F
`P’TF
`I] 1
`E 4 D4
`
`DEF
`[:1 1
`
`Incorporated or Principal Place
`ofBusiness In This Stale
`
`Citizen of This State
`
`[:I 2 US. Government
`Defendant
`
`134 Diversity
`{Indicate Citizenship Qfl’anies' in Item N!)
`
`Citizen ofAnother State
`
`1] 2 D 2
`
`incorporated and Principal Place
`of Business In Another Stale
`
`El 5 D 5
`
`Citizen or Subject of a
`Foreign Country
`
`El 3
`
`[:I 3
`
`Foreign Nation
`
`D 6 D6
`
`Click hBerBform_ , _ _
`
`
`
`IV. NATURE OF SUIT {Place an “fit" in One Btu ()nl')
`
`
`422BAppealm28 USC 158
`l 10 lnsunulcc
` 375 False Claims Act
`
`PERSONAL INJURY
`PERSONAL INJURY I 625 Drug Related Seizure
`
`
`
`
`
`
`
`423 Withdrawal
`120 Marine
`3‘76 Qui Tam [31 USC
`I 310 Airplane
`[j 365 Personal injury —
`28 USC 15?
`130 Miller Act
`
`
`3729(a))
`
`I 315 Airplane Product
`Product Liability
`I 690 Other
`
`
`I 400 State Reapponlonment
`Liability
`El 367 Health Card
`140 Negotiable Instrument
`
`7
`150 Recovery ovacrpayment I 320 Assault, Libel &
`Pharmaceutical
`410 Antitrust
`
`
`
`820 Copyrights
`& Enforcement of Judgment
`Slander
`Personal Injury
`430 Banks and Banking
`
`
`330 Patent
`I 330 Federal Employers‘
`151 Medicare Act
`Product Liability
`450 Commerce
`
`
`
`835 Patent - Abbreviated
`152 Recovery of Defaulted
`Liability
`D 368 Asbestos Personal
`460 Deportation
`
`New Drug Application
`I 340 Marine
`Student Loans
`injury Product
`470 Racketeer influenced and
`
`
`
`840 Trademark
`I 345 Marine Product
`(Excludes Veterans)
`Liability
`Corrupt Organizations
`
`
`
`880 Defend Trade Secrets
`I] 153 Recovery of Overpayment
`Liability
`480 Consumer Credit
`
`
`
`370 Other Fraud
`I 350 Motor Vehicle
`Act of2016
`of Veteran‘s Benefits
`(15 USC 1681 or 1692)
`
`I 355 Motor Vehicle
`B 371 Truth in Lending
`D 160 Stockholders‘ Suits
`435 Telephone Consumer
`
`
`Product Liability D 380 Other Personal
`190 Other Contract
`Protection Act
`195 Contract Product Liability I 360 Other Personal
`Property Damage
`490 CablcfSal TV
`
`
`196 Franchise
`Injury
`D 385 Property Damage
`862 Black Lung (923)
`850 Securitietii'Commodities.t
`
`363 DIWCi’DIWW (40503))
`I 362 Personal Injury -
`Product Liability
`Exchange
`
`
`
`_
`Medical Malpractice
`390 Other Statutory Actions
`v
`_ 891 Agricultural Acts
`
`893 Environmental Matters
`
`__
`
`I 230 Rent Lease dc Ejectment
`_
`'
`__
`870 Taxes (U.S. Plaintiff
`
`I 240 Torts to Land
`or Defendant)
`'
`
`'
`I 245 Tort Product Liability
`'
`
`U290 All Other Real Property
`
`
`I 462 Naturalization Application
` Employment .
`
`I 446 Amer, wi’Disabilil'ics - I 540 Mandamus 8: Other I 465 Other Immigration
`
`
`Other
`I 550 Civil Rights
`
`Actions
`
`
`I 448 Education
`I 555 Prison Condition
`
`
`
`I 560 Civil Detainee —
`
`
`Conditions of
`
`Confinement
`
`V. ORIGIN (PIECE an “X“ in One Bar Only)
`
`89S Freedom of lnformati on
`Act
`B96 Arbitration
`89‘) Administrative Procedure
`Aett’Review or Appeal of
`Agency Decision
`950 Constitutionality of
`State Statutes
`
`
`
`El 1 Original
`Proceeding
`
`D2 Removed fi'on'l
`State Court
`
`[:1 3
`
`Remanded from
`Appellate Court
`
`E14 Reinstated or Cl 5 Transferred fi'om El 6 Multidistrict
`Reopened
`Another District
`Litigation -
`(specifil)
`Transfer
`Cite the US. Civil Statute under which you are filing (Do not citejurisdictional mailer unless- dimly):
`42 USC Section 1981
`
`El 8 Multidistrict
`Litigation -
`Direct File
`
`V1. CAUSE OF ACTION
`
`Brief description of cause:
`Employmentdiscrimination - race and retaliation
`
`V". REQUESTED [N
`[3 CHECK IF THlS IS A CLASS ACTION
`DEMAND 5
`CHECK YES only ifdemanded in complaint:
`
`COM PLAINT:
`UNDER RULE 231 F-R-CV-P-
`JURY DEMAND:
`[3ch Elm
`
`VIII. RELATED CASE(S)
`IF ANY
`
`_
`1
`(bee rnstnrctmrrs).
`
`JUDGE
`
`NONE
`
`DOCKET NUMBER
`
`
`
`RECEIPT it
`
`AMOUNT
`
`APPLYING lFP
`
`JUDGE
`
`MAG. JUDGE
`
`

`

`UNITED STATES DISTRICT COURT
`FOR THE EASTERN DISTRICT OF PENNSYLVANIA
`
`DESIGNATION FORM
`(to be used by comma! or pro se ptairttrfl’to indicate the category ofthe casefor the purpose ofassigmnent to the appropriate calendar)
`
`Address of Plaintiff:
`
`Address of Defendant:
`
`Philadelghia PA
`
`Philadelphia PA
`
`Place of Accident, Incident or Transaction:
`
`Philadelghia PA
`
`RELATED CASE, IF ANY:
`
`Case Number:
`
`None
`
`Judge:
`
`Date Tenninated:
`
`Cit’il cases are deemed related when Yes is answered to any of the following questions:
`1 .
`Is this case related to property included in an earlier numbered suit pending or within one year
`previously terminated action in this court?
`
`Does this case involve the same issue of fact or grow out of the same transaction as a prior suit
`pending or within one year previously terminated action in this court?
`
`Does this case involve the validity or infringement ofa patent already in suit or any earlier
`numbered ease pending or within one year previously terminated action of this court?
`
`Is this case a second or successive habeas corpus, social security appeal. or pro se civil rights
`case filed by the same individual?
`
`Yes D
`
`Yes D
`
`Yes D
`
`Yes E]
`
`No
`
`I certify that, to my knowledge, the within case B is l E is not
`this court except as noted above.
`
`related to any case now pending or within one year previously terminated action in
`
`Attorney LD. it (ifapplicable)
`
`CIVIL: (Place a v in one category only)
`A.
`
`Federal Question Cares:
`
`
`
`Indemnity Contract, Marine Contract, and Ali Other Contracts
`FELA
`
`Jones Act-Personal Injury
`Antitrust
`Patent
`
`Labor-Management Relations
`Civil Rights
`Habeas Corpus
`Securities Act(s) Cases
`. Social Security Review Cases
`. All other Federal Question Cases
`(Please specify):
`
`.
`
`Diversity Jurisdiction Cases:
`
`CIDEIEIEJEIEIEIEI9‘
`
`99°99‘E-"PPE‘JT‘
`
`Insurance Contract and Other Contracts
`
`Airplane Personal Injury
`Assault. Defamation
`Marine Personal Injury
`Motor Vehicle Personal Injury
`Other Personal Injury (Please spec-i350:
`Products Liability
`Products Liability — Asbestos
`All other Diversity Cases
`(Plea-W! Wet-1157):
`
`El
`E]
`El
`III
`
`E E
`
`l E E
`
`l
`
`ARBITRATION CERTIFICATION
`( The efi‘bct ofthis certification is to remove the casefrom eligibilnyfor arbitration.)
`
`RObert T Vance J r
`
`, counsel of record or pro se plaintiff, do hereby certify:
`
`Pursuant to bowl Civil Rule 53.2, § 3(c) (2), that to the best of my knowledge and belief, the damages recoverable in this civil action case
`exceed the sum of $l50.000.00 exclusive of interest and costs:
`
`Relief other than monetary damages is sought.
`
`DATE:
`
`'
`Attornevw-Luw / Pro Se Plat
`
`*
`
`37692
`Attorney LD. # tifapplicable)
`
`NOTE: A trial de novo will be a trial byjury only if there has been compliance with F.R.C.P. 38.
`
`Cir. 609 (372018)
`
`

`

`United States District Court for the Eastern District of Pennsylvania
`
`Andrea Summers
`
`vs
`
`The Children’s Hospital of Philadelphia
`
`Civil Action No.
`
`Jury Trial Demanded
`
`Plaintifi‘, Andrea Summers, brings a series of claims against Defendant, The Children’s '
`
`Complaint
`
`Hospital of Philadelphia, of which the following is a statement:
`
`Jurisdiction and Venue
`
`1.
`
`This Court has original jurisdiction to hear this Complaint and adjudicate the
`
`claims stated herein under 28 U.S.C. §§ 1331 and 1343, the Civil Rights Act of 1866, 42 U.S.C.
`
`§ 1981 (“Section 1981”), and the Civil Rights Act of 1991, Pub. L. 102-166, 105 Stat. 1071
`
`(Nov. 21, 1991), to redress and enjoin the discriminatory practices of defendant.
`
`2.
`
`Venue is proper in this judicial district pursuant to 28 U.S.C. § 1391(b).
`
`The Parties
`
`3.
`
`Plaintiff, Andrea Summers, is an African-American female citizen of the United
`
`States and a resident of this judicial district.
`
`4.
`
`Defendant The Children’s Hospital of Philadelphia is a charitable 501(c)(3)
`
`nonprofit hospital organization devoted exclusively to the care of children. Defendant’s
`
`principal place of business is located at 3401 Civic Center Boulevard, Philadelphia, Pennsylvania
`
`19104.
`
`

`

`5.
`
`The acts set forth in this Complaint were authorized, ordered, condoned, ratified
`
`and/or done by defendant’s officers, agents, employees and/or representatives while actively
`
`engaged in the management of defendant’s business.
`
`Background Facts
`
`6.
`
`Ms. Summers worked for defendant as a Nursing Assistant in the Neonatal
`
`Intensive Care Unit CNICU) for over 20 years until she was terminated on November 17, 2020
`
`because of her race and in retaliation for reporting two of her White female supervisors, Holly
`
`Sabatino, defendant’s Nurse Manager, and Tracy Windemere, Sabatino’s supervisor, to
`
`defendant’s Compliance Department for inappropriate conduct directed towards her.
`
`7.
`
`In March and April 2020, Ms. Summers reported Sabatino to defendant’s
`
`Compliance Department twice for communicating with Ms. Summers in a disrespectful manner
`
`and for falsely accusing Ms. Summers delayed delivery of a patient from one floor to another.
`
`8.
`
`In March or April 2020, Ms. Summers reported Windemere to defendant’s
`
`Compliance Department for falsely accusing Ms. Summers of taking an unauthorized work
`
`break.
`
`9.
`
`Subsequent to reporting Sabatino to defendant’s Compliance Department,
`
`Sabatino began to interact and speak to Ms. Summers in a condescending manner, unlike the
`
`way she interacted with non-White Nursing Assistants.
`
`10.
`
`Sabatino’s mistreatment of Ms. Summers continued until October 6, 2021, when
`
`Sabatino issued a Disciplinary Action Report to Ms. Summers, allegedly for having violated
`
`defendant’s policy C7. Attached hereto as Exhibit A and made a part hereof is a true and correct
`
`copy of the Disciplinary Action Report dated October 6, 2020.
`
`

`

`11.
`
`As a result of the October 6, 2020 Disciplinary Action Report, Ms. Summers was
`
`suspended from work fi'om October 7-16.
`
`12.
`
`There was no justification for the October 6, 2020 Disciplinary Action Report;
`
`Ms. Surmners did not violate defendant’s policy C7.
`
`13.
`
`Sabatino issued the October 6, 2020 Disciplinary Action Report to Ms. Summers
`
`because of her race and in retaliation for Ms. Summers having reported Sabatino to defendant’s
`
`Compliance Department.
`
`14.
`
`On October 14, 2020, Sabitino issued another Disciplinary Action Report to Ms.
`
`Summers, allegedly for having violated defendant’s policy C22. Attached hereto as Exhibit B
`
`and made a part hereof is a true and correct copy of the Disciplinary Action Report issued
`
`October 14, 2020.
`
`15.
`
`As a result of the October 14, 2020 Disciplinary Action Report, Ms. Summers
`
`was placed on a Performance Improvement Plan (PIP), required to enter defendant’s Employee
`
`Assistance Program (EAP) and attend five sessions of company-sponsored therapy with Cura
`
`Linc Healthcare and meet with Sabatino every other week. Attached hereto as Exhibit C and
`
`made a part hereof is a true and correct copy of the PIP.
`
`16.
`
`There was no justification for the October 14, 2020 Disciplinary Action Report or
`
`the PIP; Ms. Summers did not violate defendant’s policy C22.
`
`17.
`
`Sabatino issued the October 14, 2020 Disciplinary Action Report to Ms. Summers
`
`and placed her on 21 PIP because of her race and in retaliation for Ms. Summers having reported
`
`Sabatino to defendant’s Compliance Department.
`
`18.
`
`On November 17, 2020, Sabatino issued 3 Disciplinary Action Report to Ms.
`
`Summers, allegedly for having violated defendant’s policy C17. Attached hereto as Exhibit D
`
`

`

`and made a part hereof is a true and correct copy of the Disciplinary Action Report dated
`
`November 17, 2020.
`
`19.
`
`As a direct result of the November 17, 2020 Disciplinary Action Report, Ms.
`
`Summers’ employment was terminated.
`
`20.
`
`There was no justification for the November 17, 2020 Disciplinary Action Report;
`
`Ms. Summers did not violate defendant’s policy C17.
`
`21.
`
`Sabatino issued the November 17, 2020 Disciplinary Action Report and
`
`terminated Ms. Summers’ employment because of her race and in retaliation for Ms. Summers
`
`having reported Sabatino to defendant’s Compliance Department.
`
`22.
`
`Ms. Summers has suffered, is now suffering and will continue to suffer emotional
`
`distress, mental anguish, loss of enjoyment of life and other non-pecuniary losses as a direct and
`
`proximate result of defendant’s discrimination and retaliation.
`
`23.
`
`Defendant discriminated against Ms. Summers because of her race, and retaliated
`
`against her for exercising her right to complain about Sabatino’s race discrimination.
`
`24.
`
`By reason of defendant’s discrimination and retaliation, Ms. Summers. suffered
`
`extreme harm, including loss of income and other employment benefits, loss of professional
`
`opportunities, embarrassment and humiliation.
`
`25.
`
`Defendant acted and failed to act willfully, maliciously, intentionally and with
`
`reckless disregard for Ms. Summers’s rights.
`
`Count I
`
`The Civil Rights Act at 1866, 42 US. C. §1981
`
`26.
`
`Plaintifl restates and realleges paragraphs 1—26, inclusive, as though set forth here
`
`infull.
`
`

`

`27.
`
`Ms. Summers had a federal statutory right under the Civil Rights Act of 1866, 42
`
`U.S.C. §l98l (“Section 1981”), to be accorded the same rights as were enjoyed by White
`
`employees with respect to the terms and conditions of their employment relationship with
`
`defendant and to the enjoyment of all benefits, privileges, terms and conditions of that
`
`relationship.
`
`28.
`
`Defendant’s conduct deprived Ms. Summers of the rights, privileges and
`
`immunities guaranteed to her under Section 1981.
`
`29.
`
`By reason of defendant’s conduct, Ms. Summers is entitled to all legal and
`
`equitable relief available under Section 1981.
`-
`July Demand
`
`30.
`
`Ms. Summers hereby demands a trial by jury as to all issues so triable.
`
`Prayerfor Relief
`
`Wherefore, Plaintiff, Andrea Summers, respectfully prays that the Court:
`
`a.
`
`adjudge, decree and declare that defendant engaged in illegal race discrimination
`
`and retaliation, and that the actions and practices of defendant complained of herein are violative
`
`of her rights under Section 1981;
`
`b.
`
`order defendant to provide appropriate job relief to Ms. Summers, including
`
`reinstatement;
`
`c.
`
`enter judgment in favor of Ms. Summers and against defendant for all available
`
`remedies and damages under law and equity, including, but not limited to, back pay, front pay,
`
`reinstatement, past and future mental anguish and pain and suffering, in amounts to be
`
`determined at trial;
`
`

`

`d.
`
`order defendant to pay the attorney’s fees, costs, expenses and expert witness fees
`
`of Ms. Summers associated with this case;
`
`e.
`
`grant such other and further legal and equitable relief as may be found appropriate
`
`and as the Court may deem just or equitable; and
`
`f.
`
`retainjurisdiction until such time as the Court is satisfied that defendant has
`
`remedied the unlawful and illegal practices complained of herein and is determined to be in full
`
`compliance with the law.
`
`
`
` obert T Vance Jr
`
`Law Offices of Robert T Vance Jr
`
`100 South Broad Street, Suite 905
`Philadelphia PA 19110
`215 557 9550 tel / 215 278 7992 fax
`waneedfivancelfcom
`
`Attorneyfor Andrea Summers
`
`

`

`Exhibit A
`
`

`

`
`
`.
`
`Children's Hospital
`01‘ Philadelphla"
`
`Effective Date: 06/29/2017
`
`Job Aid: 5-2A Disciplinary Action Report
`
`Date.
`To:
`
`October 6, 2020
`Andrea Summers
`
`Employee ID: 830240
`Position:
`SNA
`
`Holly Sabatino
`From:
`Rule Violated
`A
`
`C 7
`
`Please describe the behavior or incident.
`
`Department: NICU-West2
`
`According to policy CT: Employees are expected to interact with others in a polite and professional
`
`manor. Rude, insulting and/or discourteous behavior is unacceptable and will warrant a discipline.
`
`On October 2nd 2020 Andrea was unprofessional in her actions while-l was trying to have a conversation with her.
`
`
`THE FOLLO WHNGAFTJON IS BEING TAKEN:
`
`VVVVV
`
`Level 1: General Counseling
`Leve12: Oral Warning
`Level 3: Written Warning
`Level 4: Final Warning
`Termination
`
`FURTHER INCIDENTS MAY RESULT IN THE FOLLOWING ACTIONS: (Depending on
`seriousness of the infraction)
`
`VVVVV
`
`Level 2: Oral Warning
`Level 3: Written Warning
`
`Level 4: Final Warning
`Termination
`
`Subject to multiple rules violation, Section VI
`
`I HAVE READ AND I UNDERSTAND THE ABOVE DISCIPLINARY ACTION
`
`EMPLOYEE SIGNATUREW DATE:
`
`lo] '51 is} (2
`
`Please indicate refiisal to sign by initialing
`
`DATE:
`
`
`
`4/er MM! 11’ DATE:
`
`[0/0/29
`
`(
`
`pervisor’s name and title)
`
`WITNESS SIGNATURE:
`
`DATE:
`
`DELEGATE SIGNATURE;7@ M W DATE:
`
`1 O i l :1 (’20
`
`Note: Discipline can be conducted in the presence of a third person acting as a witness if
`appropriate. Employee signature does not constitute agreement.
`
`

`

`'51
`I.
`Children's Hospital
`
`1 Of Philadelphia“
`
`Effective Date: 06l29l2017
`
`Job Aid: 5-2A Disciplinary Action Report
`
`Employee Assistance Program: (888)321~4433
`
`

`

`Exhibit B
`
`

`

`,4
`
`. 5,53E.
`.;_
`
`
`
`
`E Children's Hospital
`of Philadelphia
`
`Effective Date: 0612912017
`
`Job Aid: 5-2A Disciplinary Action Report
`
`October 6, 2020
`Date: ——————_—_
`To:
`Andrea Summers
`
`Employee ID:
`Position:
`
`830240
`
`SNA
`
`Holly Sabatino
`From:
`Rule Violated
`A
`
`C 22
`
`Please describe the behavior or incident.
`
`Depamnemz NICU-West2
`
`According to Human Resource Policy and Procedure No. 5-2. C-22. employees are expected to work in a courteous and professional manner.
`
`Disputes should be approached with a calm demeanor with the intent to resolve the issue. All verbal andlor physical threats. bullying. vicious or malicious words
`
`
`or forms of aggressive behavior are prohibited and will warrant a Level 4:Final weming or Termination. While I was addressing the Written Warning discipline for unprofessional
`
`
`THE FOLLOWING ACTION IS BEING TAKEN:
`
`VVVVV
`
`Level 1: General Counseling
`Leve12: Oral Warning
`Level 3: Written Warning
`Level4: Final Warning
`Termination
`
`FURTHER INCIDENTS MAY RESULT [N THE FOLLOWING ACTIONS: (Depending on
`seriousness of the infraction)
`
`VVVVV
`
`Level 2: Oral Warning
`Level 3: Written Warning
`Level 4: Final Warning
`Termination
`
`Subject to multiple rules violation, Section VI
`
`I HAVE READ AND I UNDERSTAND THE ABOVE DISCIPLINARY ACTION
`
`EMPLOYEE SIGNATURE:tha~€@ iii/MIXEATE:
`
`l 5 Z W [a 6
`
`Please indicate refusal to sign by initialing
`
`DATE:
`
`ISSUEDBYWéMMMflMLDME l0 // 4by
`
`upervisor’s name and title)
`
`WITNESS SIGNATURE:
`
`DATE:
`
`DELEGATE SIGNATURE; EM {2122 5% DATE:
`
`/0 Z / V [.25
`
`Note: Discipline can be conducted in the presence of a third person acting as a witness if
`appropriate. Employee signature does not constitute agreement.
`
`

`

`
` Children’s Hospital
`of Philadelphia“
`
`Effective Date: 06/29/2017
`
`Job Aid: 5-2A Disciplinary Action Report
`
`EmployeeID: 830240
`October 6, 2020
`Date:
`To: W position;
`SNA
`From:
`Holly Sabatmo
`Department: NICU-West2
`Rule Violated
`A
`
`C 22
`
`Please describe the behavior or incident.
`
`behavior, Andrea stood up in my office, took the discipline paper, ripped it up, threw
`
`the paper and left my office while slamming my office door shut. HR business partner Katie Queen McPherson was present.
`
`The discipline issued is a Level 4:Final Warning. Further incidents will result in Termination
`
`THE FOLLOWING ACTION IS BEING TAKEN:
`
`VVVVV
`
`Level 1: General Counseling
`Level 2: Oral Warning
`Level 3: Written Warning
`Level4: Final Warning
`Termination
`
`FURTHER INCIDENTS MAY RESULT IN THE FOLLOWING ACTIONS: (Depending on
`seriousness ofthe infraction)
`
`VVVVV
`
`Level 2: Oral Warning
`Level 3: Written Warning
`Level 4: Final Warning
`Termination
`
`Subject to multiple rules violation, Section VI
`
`I HAVE READ AND I UNDERSTAND THE ABOVE DISCIPLINARY ACTION
`
`EMPLOYEE SIGNATURE:
`
`DATE:
`
`Please indicate refilsal to sign by initialing
`
`DATE:
`
`ISSUED BY: ___—___ DATE:
`(Supervisor’s name and title)
`
`WITNESS SIGNATURE:
`
`DELEGATE SIGNATURE:
`
`DATE:
`
`DATE:
`
`Note: Discipline can be conducted in the presence of a third person acting as a witness if
`appropriate. Employee signature does not constitute agreement.
`
`

`

`o 1TQTHXE
`
`

`

`Name of Manager: Holly Sabatino
`
`Signature of Manager:
`
`Date:
`
`Employee Signature:
`
`Date:
`
`Immediate, significant and sustained improvement in all areas noted within this Performance Improvement Plan (PIP) must occur. Failure
`to satisfy the performance expectations as agreed may result in further disciplinary action up to and including termination. If there is not
`significant improvement to indicate that the goals and expectations as outlined in this PIP will be met within the established timeframe,
`your employment may be terminated prior to the end of the expected completion date.
`
`If after successfully completing the PIP the employee’s performance declines, immediate termination of employment from The Children’s
`Hospital of Philadelphia may occur without issuance of a disciplinary warning or another improvement plan.
`
`

`

`CURA CO LINC
`
`H E A LTHCARE
`
`Authorization for Disclosure of Records 8:
`
`Communications
`
`Release of Information
`
`I, ANDREA SUMMERS hereby consent and authorize CuraLinc Heaithcare, or its employee, agent or designee to disclose my mental health
`and/or alcohol/drug abuse records and communications {including the fact whether or not I kept my appointment with CuraLinc or other
`service provider) to the following individual(s) and/or organization, under the conditions listed below:
`1.
`Name of personis). agency or organization and address to whom disclosure/exchange is to be made:
`Katie Queen-McPheison or employer designated representative.
`Nature of information to be di5closed:
`
`
`
`
`
`
` D Treatment Summary
` [2] Attendance
`
`[:3 Discharge Summary
`flOther:_
`
`
`III Results of Drugi'Alcohol Testing
`
`l3 Recommendations
`
`Progress
`
`
`
`
`3.
`
`The purpose of the disclosure:
`
`CI Continuity of Treatment
`E Verification of compliance/noncompliance with EAP recommendations
`E Contact with Referring Supervisor
`|:| Referral
`'
`I] Other:
`
`
`
`El Aftercare Planning
`
`Signatures o'fConsent
`
`7 _
`
`.
`
`-
`
`
`
`
`
`
`
`
`This consent will terminate upon (state specific calendar date): 10/12/2021 (If no calendar date is stated, information may be released only on
`the date CuraLinc or other service provider receives this form).
`Ifl refuse to consent to this release of information. the following are the consequences (specify, ifany}: Unable to re on com liance to em Io er.
`
`A carbon copy or photocopy of this consent shall have the same force and effect as the original.
`
`Signed:
`Date:
`
`
`- 1:!
`‘
`
`
`
`Client (lfunderIZYears,fn P
`
`the-al Guardian]
`
`Witness: i-LA
`Ine ho can attesttothwItyofthe I-' my)
`
`Date:
`
`-
`
`'
`
`'
`
`Notice: I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy
`regulations promulgated pursuant to the Health Insurance Portability and Accountability Act (”HIPPA"). However. information regarding HIWAIDS. mental health and drug or alcohol abuse
`may not be redisclosed by the person authorized herein to receive such information without my express written consent. I understand that CuraLinc may not condition treatment, payment.
`enrollment or eligibility for benefits on whether I sign this Authorization.
`NOTE TO RECEIVING AGENCWPERSON: This information has been distiosed to you from records protected by Federal confidentiality rules (42 CFR, Part 2). The Federal rules prohibit
`you from making anyfu rther disclosure ofthis information uniess further disclosure is expressly permitted by the written consent ofthe person to whom it pertains or as otherwise permitted
`by 42 CFR, Part 2. A general authorization for the release ofmedical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally
`investigate or prosecute any alcohol or drug abuse patient. State law regarding the confidentiality of mental health records also prohibits redisclosure of this information without the
`specific consent of the person who consented to the disclosure.
`
`rttficationof interpretation
`
`Iccertify that l have read the foregoing to the signatory hereofin the
`
`language.
`
`Interpreter:
`
`Witness:
`
`Revocation of Consent
`
`‘
`
`I understand that I have the
`I may revoke this consent at any time by signing below or by sending a written request to Cure Linc Healthcare.
`right to inspect and copy the information to be disclosed. However, I agree to release and hold harmless Cura Linc Healthcare and its
`employees and/or agents for any disclosure made prior to CuraLinc's receipt of the written revocation of this authorization.
`
`As of this date, I hereby revoke the consent provided on this authorization form.
`
`Signed:
`
`
`
`til
`
`7.
`
`i
`
`
`
`

`

`Exhibit D
`
`

`

` we
`
`of Philadelphia“
`
`Effective Date: 06/29/2017
`
`Job Aid: 5-2A Disciplinary Action Report
`
` Date: November 17,2020
`
`To:
`Andrea Summers
`From:
`Holly Sabatino
`Rule Violated
`A
`
`c 17
`
`Employee ID: 830240
`Position:
`SNA
`Depmm NICU West 2
`
`Please describe the behavior or incident.
`
`According to PolicyzRules of Conduct 017-employees are expected to be in their assigned work areas except for scheduled (assigned)
`
`
`lunch or other breaks. Any unauthorized absence from their assigned work area (as defined by the supervisor) of one hour or more will warrant
`
`
`Level 4:Final Warning or Termination. On October 17th, Andrea was assigned to 93 for her shift. She went on break at 13:53
`
`W T
`
`HE FOLLOWING ACTION IS BEING TAKEN:
`
`VVVVV
`
`Level 1: General Counseling
`Level 2: Oral Warning
`Level 3: Written Warning
`Level 4: FinalWaming
`Termination
`
`FURTHER INCIDENTS MAY RESULT IN THE FOLLOWING ACTIONS: (Depending on
`seriousness ofthe infraction)
`
`VYVVV
`
`Level 2: Oral Warning
`Level 3: Written Warning
`Level 4: F inal Warning
`Termination
`
`Subject to multiple rules violation, Section VI
`
`I HAVE READAND I UNDERSTAND THE ABOVE DISCIPLINARY ACTION
`
`EMPLOYEE SIGNATURE:
`
`DATE:
`
`Please indicate refusal to sign by initialing_a;_a3_ DATE——
`ISSUEDBY (34/
`Jfi/‘Wfiw
`DATE:
`”’ 'TIWW
`
`(S
`
`ervisor’3 name and title)
`
`WITNESS SIGNATURE:
`
`DATE:
`
`DELEGATESIGNATURE:7_ZZZ—7&7Mg::3ATE‘W7
`
`Note: Discipline can be conducted1n the presence of a third person acting as a witness if
`appropriate. Employee signature does not constitute agreement.
`
`

`

`
`Children's Hospital
`
`r 0f Philadelphia“
`
`Effective Date: 06/29I2017
`
`Job Aid: 5-2A Disciplinary Action Report
`
`Date: W Employee ID: 830240
`To: W position;
`§NL____
`From:
`Holly Sabatlno
`Department: NICU West 2
`Rule Violated
`A
`
`C 1 7
`
`Please describe the behavior or incident.
`
`per the 98 Charge RN and did not return to work on the unit 1540. After further investigation
`
`this information coincides with Andrea's badge in swipes at both the NICU locker room as well as the
`
`South tower elevator to return to SS. Given that this time frame exceeds the alloted time of break it warrants Level 4 Termination
`
`THE FOLLOWING ACTION IS BEING TAKEN:
`
`VVVVV
`
`Level 1: General Counseling
`Leve12: Oral Warning
`Level 3: Written Warning
`Level4: Final Warning
`Termination
`
`FURTHER INCIDENTS MAY RESULT IN THE FOLLOWING ACTIONS: (Depending on
`seriousness ofthe infraction)
`
`VVVVY
`
`Level 2: Oral Warning
`Level 3: Written Warning
`Level 4: Final Warning
`Termination
`
`Subject to multiple rules violation, Section VI
`
`I HAVE READ AND I UNDERSTAND THE ABOVE DISCIPLINARY ACTION
`
`EMPLOYEE SIGNATURE:
`
`DATE:
`
`Please indicate refilsal to sign by initialing
`
`DATE:
`
`ISSUED BY:
`
`' (Supervisor’s name and title)
`
`WITNESS SIGNATURE:
`
`DELEGATE SIGNATURE:
`
`DATE:
`
`DATE:
`
`DATE:
`
`Note: Discipline can be conducted in the presence of a third person acting as a witness if
`appropriate. Employee signature does not constitute agreement.
`
`