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32 | sure that the alert system was functioning properly. Although the alert was flashing in R1's room, it was not registering at the computer at the front desk. Staff suggested that perhaps the alert had been reset because staff arrived after the LPA left R1's room and that was why it was no longer registering at the front desk. The LPA went back to R1's room and verified that the alert was still in the pulled position and flashing. The alert was malfunctioning.
This LPA obtained the alert call log for the month of January. There were over 4,000 alerts activated for that month. This LPA selected 01/01/24 to review. There were 139 alerts activated on that day. 96 were responded to within the 5-7 minute time frame set down by the administration. An additional 16 were responded to in under 15 minutes. 10 were responded to within 15 - 25 minutes 12 were responded to between 25 and 40 minutes. These results show a marked improvement over the response times shared during the NCC meeting on 11/09/23, however the standard 5-7 minute response time set by the Licensee was not met and there was still at least 1 alert call unit in need to repair. The preponderance of evidence standard has been met, and this allegation has been SUBSTANTIATED. This deficiency is cited on the 9099D page.
A copy of this report was provided.
Exit interview.
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