"Systemic Deficiency" - the definition reads violations of regulations documented by the department that demonstrate multiple or repeated defects in the operation of one of more service.  

Because there are not clear parameters for multiple or repeated - OL has already interpreted this to the most extreme measure in a recent CAP for our organization.    We received 2 CAPS for the same regulation but for very different issues that did not reflect a systemic issue within the organization.   Many regulations encompass various systems, both internal and external, therefore more than one citation of the same regulation does not necessarily constitute a systemic deficiency within the organization.  I am happy to provide concrete examples if that would be helpful.