CVS Health, one of the nation’s largest operators of retail chain pharmacies, will pay Ohio $1.5 million in penalties for problems largely related to understaffing and make changes that may soon be mandatory for all the state’s retail pharmacies, the Ohio Board of Pharmacy said Thursday.

The penalties, the largest ever imposed by the state board, are part of the settlement of 27 safety cases the board was investigating at 22 CVS pharmacies.

The 27 cases alleged numerous safety concerns and potential legal violations found during a series of inspections of those stores between 2020 and 2023, and found that understaffing contributed significantly to many of the issues. Inspectors identified insufficient staff for the volume of prescriptions, dispensing errors, prescription delays, dirty equipment, trash throughout the pharmacies, expired medications, poor drug security and failure to report losses of controlled substances, among other issues.

“By entering into this settlement agreement, the Board seeks immediate and systemic changes to protect patients and address critical understaffing,” said Steven Schierholt, executive director of the State of Ohio Board of Pharmacy. “We believe that this agreement is an acknowledgement by CVS that considerable changes are warranted to ensure the safe practice of pharmacy at their retail stores.”

The agreement included the rare step of placing the eight stores with the biggest staffing issues under “advanced monitoring” by the board, to be funded by CVS, for the next three years. CVS also agreed to voluntarily comply with several not-yet-finalized state rules focused on patient safety. Those include implementing mandatory rest breaks, dispensing prescriptions within three days or less, and instituting a process for staff to notify management of understaffing.

The proposed state rules CVS agreed to follow may soon apply to all pharmacies in the state, as the board expects them to be finalized within the next few months.

CVS Health has more than 9,000 retail locations nationwide and is the largest U.S. pharmacy by revenue. It is the largest operator of retail pharmacies in Ohio. Spokesperson Amy Thibault said that CVS is “pleased to have reached an agreement with the Ohio Board of Pharmacy regarding years-old allegations involving some of our Ohio pharmacies” and that the company looks forward to working with the board, including on “enhancing our positive identification systems, and continuing to provide safe, high-quality pharmacy care to our patients.”

Employees at retail chain pharmacies have been sounding the alarm over patient and workplace safety concerns related to understaffing for years. Profit margins for retail pharmacies began shrinking more than a decade ago, putting a squeeze on the industry. Workers say staffing shortages worsened during the pandemic while job responsibilities increased, leading to medication delays and increasing the likelihood of mistakes, such as miscounting or selecting the wrong medication when filling prescriptions. 

In response to staffing concerns, in the past several years CVS and other retail pharmacy chains have made large hiring pushes, increased wages and even done away with some metrics. Outcry from workers — who are largely nonunionized — has continued, including some work stoppages at retail chains in the fall.

“We’re committed to ensuring there are appropriate levels of staffing and resources at our pharmacies and are making targeted investments,” Thibault said. That includes increasing pharmacist wages roughly $1 billion between 2021 and 2024 and awarding roughly $70 million in bonuses this year to “pharmacists, pharmacy technicians and other frontline colleagues.”

Pharmacy errors can range from smaller mistakes, like miscounting the number of pills in a bottle, to potentially deadly ones, like missing a dangerous drug interaction. Pharmacy workflows include checks to prevent and catch such errors, but as pharmacists and technicians become more overworked, the more likely they are to make and miss errors, pharmacy experts say, raising concerns from state regulators. 

At one Ohio store, state inspectors found the pharmacy would “close intermittently due to understaffing,” preventing patients from receiving their medications. At another, inspectors noted that “although the pharmacy is closed for lunch, staff rarely stop to take a break or eat because they are so far behind.” Both those inspections occurred in 2022.

Several state pharmacy boards, which regulate pharmacies, including that of Ohio, have fined retail chain pharmacies over understaffing issues in recent years. The Ohio board’s Thursday settlement marks the largest number of pharmacies and biggest monetary fine yet related to staffing in the state, possibly nationwide, board spokesperson Cameron McNamee said.

Ohio settled its 27 cases with CVS for a $1.25 million penalty. As part of the agreement, the eight stores where the board found the biggest staffing issues were placed on a three-year probation, and the company will pay an additional $250,000 “to cover the cost of enhanced monitoring by the Board.”