Guidance for Submitting Digital Evidence in Pharmacy Inspections

ACP inspections: digital evidence submission template Pharmacy information Pharmacy name: Pharmacy license # (if issued): Pharmacy licensee: Licensee registration #: Contact information: Phone: Email:

Objectives This document will provide guidance and a template to licensees who are submitting digital evidence as part of a pharmacy inspection process. Unless otherwise indicated, this template should only be submitted to ACP once all required images have been added to the document. Any required digital evidence that is not to be added into the template (as outlined in Appendix A) must be submitted separately as independent documents. Once digital evidence is submitted, your pharmacy practice consultant (PPC) will follow up with additional instructions, which may include clarification of the evidence submitted or scheduling of an inspection

Tips to avoid delays Ensure that you have read and understand the requirement(s) as outlined in the: o Foundational Requirements: Guidance Document for Opening a Licensed Pharmacy, and o Foundational Requirements Compliance Checklist. The digital evidence submitted in this template for each item must demonstrate that the item meets the legislative requirements. The digital evidence submitted must be an actual real-time depiction of your pharmacy. Photos from other pharmacies or stock photos are not acceptable. The digital evidence must be of sufficient quality and provide sufficient context for the College to assess whether the requirements are met. Please ONLY insert images in the appropriate boxes on each slide. This will prevent file sharing issues through email. If no slide is present for a particular legislative requirement, for example legislative requirement 1, this indicates the required compliance evidence will be assessed elsewhere.

Legislative requirement #2 Digital evidence required of the external premises includes: Multiple photos showing the external view of the pharmacy premises, including a panorama of surrounding and adjacent businesses. Close-up photos of the external-facing signage, including the operational hours. These photos must clearly identify the location(s) where the signage is posted. If the pharmacy is a lock-and-leave pharmacy, an additional photo displaying the operational hours of the store. Digital evidence required of the internal premises includes: Photo(s) of the prescription department taken from the internal front entry space of the premises. Close-up (5-10 feet away, facing the dispensary) photo(s) of the signage used to differentiate the prescription department from the public area. Photo(s) documenting any and all physical variations within the premises, including but not limited to flooring, decor, and fixtures.

Legislative requirement #2 (Digital Evidence of the external premises photos of the pharmacy and surrounding businesses)

Legislative requirement #2 (Digital Evidence of the external premises photos of the pharmacy and surrounding businesses)

Legislative requirement #2 (Digital Evidence of the external premises photos of the external signage for the pharmacy)

Legislative requirement #2 (Digital Evidence of the external premises photos of the signage for the operational hours of the pharmacy)

Legislative requirement #2 (Digital Evidence of the external premises photos of the signage for the use of a time-delay safe)

Legislative requirement #2 (Digital Evidence of the internal premises photos of the pharmacy and prescription department from entry to premises)

Legislative requirement #2 (Digital Evidence of the internal premises photos of the pharmacy and prescription department from entry to premises)

Legislative requirement #2 (Digital Evidence of the internal premises photos of the pharmacy and prescription department from entry to premises)

Legislative requirement #2 (Digital Evidence of the internal premises photos of the time-delay safe signage in the dispensary)

Legislative requirement #3 Digital evidence required of the security system includes: Photo(s) of all installed alarm panel(s) taken no further than 10 feet from the device. Photo(s) of any and all cameras, motion sensors, and door sensors installed in the pharmacy. o If one panoramic photo can demonstrate the installation and location of these items, that will be sufficient. Photo(s) of the viewing panel or monitor that displays the footage from the security cameras. Photo(s) of any and all security gates, bars, or window grills installed in the pharmacy NOTE: A test to determine if the alarm system is operative will be conducted at the time of the inspection.

Legislative requirement #3 (Digital Evidence of the security system alarm panel(s))

Legislative requirement #3 (Digital Evidence of the security system cameras, motion sensors, door sensors)

Legislative requirement #3 (Digital Evidence of the security system cameras, motion sensors, door sensors (2))

Legislative requirement #3 (Digital Evidence of the security system viewing panel/screen for monitor that displays camera footage)

Legislative requirement #3 (Digital Evidence of the security system security gates, grills, or bars installed in the pharmacy)

Legislative requirement #4 Digital evidence required for a lock and leave pharmacy includes: Photo(s) of the independent alarm panel taken no further than 10 feet from the device and clearly demonstrating the placement of the panel within the dispensary. Photo(s) of any and all security gates and doors that are used to close off the dispensary outside of pharmacy operational hours. Photo(s) of any and all lock and leave panels installed in the public area to restrict access to Schedule 3 products outside of pharmacy operational hours.

Legislative requirement #4 (Digital Evidence for lock and leave pharmacies independent alarm panel(s) for the dispensary)

Legislative requirement #4 (Digital Evidence for lock and leave pharmacies security gates/doors to close off dispensary outside pharmacy hours)

Legislative requirement #4 (Digital Evidence for lock and leave pharmacies installed lock and leave panels for schedule 3 products)

Legislative requirement #5 Digital evidence required for conditions in the pharmacy includes: Photo(s) of the thermostat displaying the temperature within the premises. Photo(s) of the pharmacy and consultation room with 360o views demonstrating sufficient lighting. At least 2 photos should be submitted from the dispensary itself.

Legislative requirement #5 (Digital Evidence for conditions in pharmacy thermostat and lighting)

Legislative requirement #5 (Digital Evidence for conditions in pharmacy additional photos demonstrating sufficient lighting)

Legislative requirement #6 Digital evidence required for storage includes: Photo(s) of all cabinets or shelves where drug or health care products will be stored in the dispensary. Photo(s) of all cabinets or shelves where drug or health care products will be stored in the patient services area.

Legislative requirement #6 (Digital Evidence for storage in pharmacy general photos demonstrating cabinets and shelving for drugs and health product)

Legislative requirement #6 (Digital Evidence for storage in pharmacy general photos demonstrating cabinets and shelving for drugs and health product)

Legislative Requirement # 7 Digital evidence required includes: Photos of where Schedule 1 drug products will be stored in the dispensary. Submit multiple photos from different angles to clearly demonstrate the location of the storage area. Photos of where Schedule 2 drug products will be stored in the dispensary. Submit multiple photos from different angles to clearly demonstrate the location of the storage area. Photos of where Schedule 3 drug products will be stored in the patient services area. Submit multiple photos from different angles to clearly demonstrate the location of the storage area. NOTE: Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 1 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 1 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 1 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 2 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 2 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 2 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 3 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 3 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #7 (Digital Evidence for storage in pharmacy photos identifying storage locations for Schedule 3 Drugs) Photos submitted to demonstrate compliance with legislative requirement #7 may also be representative of the required digital evidence for legislative requirement #6*

Legislative requirement #9 Digital evidence for signage includes: Photo(s) of all required signs posted within the pharmacy. Either multiple photos or one photo displaying all items may be sufficient, however the photo(s) must clearly show where the signage is posted and how this signage is visible to patients in the pharmacy. Empty frames or alternative temporary posters taped to the location where these signs will be posted are sufficient for this requirement.

Legislative requirement #9 (Digital Evidence for signage in pharmacy photos identifying signage locations for license, concerns, and Code of Ethics) Hours of Operation Signage to be submitted in slides for Requirement #2

Legislative requirement #9 (Digital Evidence for signage in pharmacy photos identifying signage locations for license, concerns, and Code of Ethics) Hours of Operation Signage to be submitted in slides for Requirement #2

Legislative requirement #9 (Digital Evidence for signage in pharmacy photos identifying placeholder locations for license, concerns, and Code of Ethics) Hours of Operation Signage to be submitted in slides for Requirement #2

Legislative requirement #9 (Digital Evidence for signage in pharmacy photos identifying internal signage locations for the time-delayed safe signage) Hours of Operation Signage to be submitted in slides for Requirement #2

Legislative requirement #11 Digital evidence for physical barriers includes: Photos of the physical material (walls, cabinets, shelving, counter-tops) used to separate the dispensary from the patient services area. o Photos should be submitted from the perspective of the dispensary as well as the public (at least one each) and should provide a panoramicview of the space. Photos of all gates, doors, or other access points from the patient services areas into the dispensary. Photos should be submitted that clearly show the location of the access gates/doors as well as the specific features of the access points (locking features of gate or door).

Legislative requirement #11 (Digital Evidence for the dispensary photos identifying barriers to entering the dispensary (internal view from dispensary)

Legislative requirement #11 (Digital Evidence for the dispensary photos identifying barriers to entering the dispensary (internal view from dispensary)

Legislative requirement #11 (Digital Evidence for the dispensary photos identifying barriers to entering the dispensary (external view from patient services area)

Legislative requirement #11 (Digital Evidence for the dispensary photos identifying barriers to entering the dispensary (external view from patient services area)

Legislative requirement #11 (Digital Evidence for the dispensary photos identifying gates/doors for entering the dispensary (internal view from dispensary)