In the wake of news about Ohio regulators’ findings at severely understaffed CVS pharmacies, numerous current and recent CVS workers in Ohio and elsewhere have said the problems are not limited to the nine stores the Ohio Board of Pharmacy has issued reports on.
Meanwhile, Ohio Attorney General Dave Yost called the findings in the reports “very concerning” and said that his office is “collecting information” about whether some CVS practices have violated state antitrust laws.
On July 7, the Capital Journal reported on eight Ohio CVS stores where the Board of Pharmacy found rampant turnover due to understaffing in inspections that took place between 2020 and last year. Inspectors found hundreds of problems, including dirty conditions, lack of controls over dangerous drugs and wait times as long as a month for prescriptions. They also found adulterated and expired drugs on CVS pharmacy shelves.
A ninth inspection report obtained a few weeks later found similar conditions at a ninth CVS store — this one in Willoughby — and that 1,800 doses of controlled substances couldn’t be accounted for. In addition, inspectors found an instance in which a patient was made ill by being given the wrong medication.
In responses to questions for both stories, CVS called them “isolated incidents.” But in their response to the stories, many current and recent CVS employees in Ohio and other states said the problems were far from isolated.
Understaffed by choice
Most current employees asked to remain anonymous. But one went on record to say that short staffing at CVS is not always due to a lack of qualified people to work at the stores. Minimal staffing is a conscious policy imposed on stores from above, she said.
“Understaffing is pretty deliberate from our upper and middle management,” Iggy Aleksick, a pharmacy technician at a CVS in Bowling Green, said last month. “It’s not that we don’t have people to work, it’s that we’re not allowed to be scheduled. Even in the past couple weeks, my pharmacy manager was told to cut 36 hours from her week and it was a Thursday. It wasn’t possible for her to do.”
Others said that the district and regional managers imposing such orders get bonuses based partly on savings from limiting employee hours. When asked if that were the case, a CVS spokesman didn’t answer directly.
“Patient safety is our highest priority, and decisions about staffing, labor hours, workflow process, technology enhancements and other operational factors are made to ensure we have appropriate levels of staffing and resources in place in our pharmacies,” spokesman Matthew Blanchette said in an email.
On Tuesday, CVS announced it was laying off 5,000 employees, but it said they would be “non-customer facing positions,” CNN reported. Even before the announcement, all of the current and former CVS employees who spoke to the Capital Journal described overwork in stressful conditions that made them worry about patient safety — no matter how careful they tried to be.
Amy Gilmore was a pharmacist at CVS store No. 4401 in Centerville from 2018 until last October. She described how things grew steadily worse until she finally left.
CVS, the largest pharmacy chain in the United States, for years has been buying out competitors, closing those stores and moving their prescriptions to the nearest CVS pharmacy.
It’s unclear if the Centerville pharmacy was affected the same way, but a pharmacist at another Dayton-area CVS told Board of Pharmacy inspectors that her store absorbed prescriptions from two other pharmacies without increasing its staff. That came after CVS in 2021 announced that it was closing 300 stores a year through 2024 — including least four in the Dayton area — and in many cases moving prescriptions at those stores to the closest CVS.
In any case, the staff at Gilmore’s Centerville CVS was so overloaded that it was in a constant scramble to catch up. She said she was faced with so many tardy prescriptions that it fell to patients to tell staffers when their needs were acute.
“We were triaging thousands of prescriptions that were all in the system as being overdue but we sadly didn’t know who needed what until the patients came,” Gilmore said. “We were trying to be transparent with our patients and told them if you need something, you have to call us because our system is not functioning the way it should because we’re so overloaded. There were other stores that weren’t that transparent with their patients, so those patients didn’t know what was going on.”
Working 14-hours days with few breaks in such a situation made Gilmore worry that she couldn’t do her job properly.
She tried to come up with a system of doublechecks to avoid mistakes, “but a lot of times I was getting interrupted. I try not to make any errors — I have an eye for detail — but as I was getting more fractured, things started happening where I was like, ‘Oh, I should have caught that.’ Thankfully, no harm came to my patients because of it.”
In its inspections, the Board of Pharmacy found several ways that understaffed CVS pharmacies might not have proper controls to ensure that employees weren’t stealing — or “diverting” — controlled substances such as narcotics.
In one, the pharmacy staff was too busy to retrieve a drug delivery from the front of the store for nine hours. And in a Toledo CVS, they found negative numbers suspiciously entered into the inventory system, and they couldn’t know if the purpose was “to mask the diversion of drugs received on that day,” the report said.
Gilmore said that she saw some other ways dangerous drugs could be diverted from overworked pharmacies. One was by not frequently doing physical checks — “cycle counts” — against the inventory system for single-usage painkillers that are often prescribed in the emergency room or by urgent-care centers.
“At stores that weren’t keeping up with supply management, they weren’t keeping up with cycle counts, so no one was seeing that the cycle counts were off so they couldn’t tell the system that it was off,” said Gilmore, who also served as a “floater,” or pharmacist who filled in at other CVS stores.
Another way to lose track of dangerous drugs, Gilmore said, is when they sit too long in bins waiting to be picked up. Those waits can be long, other pharmacy workers said, because CVS aggressively pushes autofill for patients who often don’t need refills yet.
Gilmore explained that at the Centerville CVS where she worked there were 144 bins for scripts and each script was assigned a bin number. But sometime after 14 days if that prescription hasn’t been removed “that bin number falls off,” she said.
When that happened, the only way to track prescriptions was to manually go through all the bins and pull all the scripts with fill dates more than two weeks earlier, Gilmore said. That’s daunting enough in a store with 144 bins, but Gilmore has subbed at stores that have 320.
“So there’s 320 bins that could have overdue narcotics that somebody could divert from,” she said, explaining that that is especially a risk if employees are aware that nobody’s really keeping track.
Asked specifically about that possibility, CVS again didn’t respond directly.
“We’re also committed to a strong culture of compliance regarding our inventory and record-keeping obligations,” Blanchette, the spokesman, said.
Same staffing, new tasks
Several current and former CVS staffers said that even as they lack time to properly consult with patients and keep them safe, constant dictates come out of corporate for them to take on new tasks, such as calling people and asking them to come pick up prescriptions or get vaccines.
“A lot of these calls are basically nonsense,” said Aleksick, who as of last week still worked at the CVS in Bowling Green.
Simon Souhrada left his job as a technician at the CVS in Mount Vernon in June. That pharmacy absorbed prescriptions from Lonsinger Pharmacy 12 miles away in Danville after buying and closing it in 2017.
The Board of Pharmacy reported mass departures by pharmacy employees at several other CVS stores. Souhrada joined one with about eight other technicians who left in frustration — and he said he expected their pharmacy manager to follow them shortly.
“The part that did it for me was just not being able to take care of the patients; getting yelled at, but also kind of deserving it because they had reason to be mad,” Souhrada said. “Patient safety was my main issue. I don’t want to be responsible for something bad happening. I know it’s a catch 22 if I leave and make it worse.”
He said a huge frustration was that the district manager didn’t provide the help they needed, but was always foisting new tasks on them.
The tasks might be related to the corporate drive to close almost 10% of its stores and turn many of the remaining ones into “HealthHubs,” which would offer traditional pharmacy services, and “have an expanded selection of products to choose from, including more products to help with chronic conditions like diabetes.” But Souhrada said employees were drowning under the traditional pharmacy tasks they already had to perform.
His district manager “had this weird focus on all of these corporate metrics, none of which helped get medications to patients,” he said. “It was all calling people, trying to sell them on vaccines and we would get daily emails demanding that we go faster and faster on these things while the queue (of unfilled prescriptions) was piling up and there was no one to fill it. She just focused on all the wrong things and didn’t do anything to help.”
Similarly, Gilmore, the former pharmacist at the Centerville CVS, said she was made responsible for setting up CPAP machines to treat sleep apnea.
“I had no idea how to do any of that,” she said. “CVS saw it as money signs — like, ‘Hey we can get money to do this,’ — but it didn’t back up or train anybody on how to do it. It was a mix of greed from the top and information not trickling down.”
Blanchette, the CVS spokesman, said the company is trying to stay on the forefront of healthcare.
“As the practice of pharmacy rapidly evolves, our pharmacists are keeping patients healthy through providing immunizations, adherence coaching, and clinical interventions,” he said. “To support our pharmacy teams’ ability to focus on patient-centric work, we continue to invest in technology and automation while being a leading advocate for states to increase pharmacy technician-to-pharmacist ratios.”
Aleksick, the tech at the Bowling Green CVS, doesn’t see it that way.
“I try my best to give good customer service, because that’s what my job is,” she said. “But my company does not prioritize me performing that well as part of my actual job. I’m just a profit generator for them. Which kind of sucks in a healthcare setting.”
Cause for concern
In an interview late last month, Yost, the Ohio attorney general, said he had been keeping up with problems the Board of Pharmacy found at some CVS stores.
“It’s very concerning,” he said. “That’s why we have a pharmacy board. These kinds of things do happen all the time and they happen in all kinds of pharmacies and pharmacy chains. Like everything with human behavior, mistakes get made and controls are not observed.”
But, Yost added, “The question is, does CVS rise to a different level from the kind of background level of mistakes that we would typically expect to see and I don’t have the answer to that.”
The attorney general’s office acts as lawyer for the pharmacy board and Yost said his office will play that role in the board’s enforcement actions against the CVS stores in which it found problems. The board will hold a hearing on Nov. 7-8 into problems found at a Canton CVS, and the board could decide to fine the store or even to revoke its license. Other hearings haven’t been scheduled yet.
But, Yost said, his office is “gathering information” on another aspect of the matter.
“There’s the whole question of the competitive marketplace and antitrust,” he said. “Healthcare is especially fraught right now in this area because as a lot of industries have previously gone through, healthcare is going through a lot of consolidation and vertical integration.”
The attorney general said it isn’t feasible to try to turn the clock back 30 years and a changing economy probably would have spelled doom for some community pharmacies even if CVS wasn’t there, trying to buy and close them.
“But on the other hand, when you buy up so many — and close them when so many were going to close anyway for economic reasons — you ought to be able to still service the patient base that you acquired through that acquisition,” Yost said. “If you buy 10 pharmacies and that represents 100,000 lives and you’re going to close all those, I would expect that the acquiring pharmacies have the ability to care for 100,000 (additional) lives.”
He added, “If they fail to do that, that is at least some evidence that this was not a market-driven issue, but predatory. It’s not dispositive and it’s not a bright line, but it’s something I’m concerned about and it’s something that we are taking measures to get information and have a better sense of what’s going on.”
Adding to antitrust concerns are long-standing allegations by community pharmacists that CVS has an inherent conflict because it owns the largest retail chain and the largest pharmacy benefit manager. The latter company, also called a PBM, decides what drugs are covered by insurance and how much to reimburse its own and its competitor pharmacies for them.
CVS maintains that it has strict firewalls between its business units. But competitor pharmacies said they saw a steep drop in CVS Caremark reimbursements in late 2016 and early 2017, followed by a flurry of letters from CVS Acquisitions offering to buy the competitors out.
Yost stressed that his office is only gathering information at this point and he didn’t discuss what an antitrust action might look like. But his office in March announced an antitrust suit against several companies, including Express Scripts, another of the big-three pharmacy benefit managers.
Louder than words
CVS spokesman Blanchette said the company wants to hear its workers’ complaints.
“We value the feedback of our employees and provide numerous resources for them to share their suggestions and concerns, anonymously if they choose, as part of our commitment to continual improvement.”
But to many current and former pharmacy employees, those assurances ring hollow.
Souhrada, the former tech at the Mount Vernon CVS, referred to the corporation’s purchase of and closure of the Danville pharmacy in 2017 — without adequately staffing the store where it transferred the prescriptions.
“CVS is moving in and not helping the people,” he said. “It was the Mount Vernon CVS putting (the Danville pharmacy) out of business, and now people can’t get their scripts at the Mount Vernon CVS.”
And Aleksick, who as of last week still worked at the Bowling Green CVS, said it’s obvious to her what CVS’s priorities are.
“They’re really concerned with efficiency and their bottom line,” she said. “I know that those people like to say, ‘Oh, we care about our patients/customers,’ but actions speak louder than words. They do not give us enough time to give good, attentive care to people who are coming into the pharmacy.”
Gilmore, the pharmacist who left the Centerville CVS last October, said corporate practices there made her question her career choice.
“I didn’t feel I had completed a good job. Even though I’d go in, work a 14-hour day and be working the entire time without breaks, I didn’t feel like I had accomplished anything. I didn’t feel like I had an impact,” she said. “It wasn’t why I went into pharmacy. It was surviving, not thriving. A lot of times at CVS, I didn’t feel like I was doing any kind of patient care beyond hopefully checking a prescription that they needed and allowing them to have that.”
CVS its critics say the company has made careers in pharmacy less appealing. It to have had that effect on Gilmore.
“If I knew what I know about pharmacy now, I probably wouldn’t have made the choice to go to pharmacy school,” she said.
This story was republished from the Ohio Capital Journal under a Creative Commons license.