Renovation

Any changes to the physical facilities, proposed use of space, or layout of a licensed pharmacy are considered renovations and require advanced notice and approval by the registrar prior to implementing these changes. The licensee should submit a complete application to renovate the pharmacy to ACP at least 45 days before construction begins.

What is considered a renovation?

A renovation includes any proposed changes to the

• overall size or layout of the pharmacy,
• size or layout of the dispensary or patient services area,
• use of space for pharmacy services, or
• counterspace.

Modifications that do not alter the previously approved floor plan or intended use of space are not considered renovations and do not require further approval (e.g., painting, changing flooring). In limited situations, an eligible community pharmacy may apply for a secondary dispensary.

If you are not sure whether the changes you are planning constitute a renovation, email pharmacy@abpharmacy.ca.

Licensees are required to ensure their pharmacy adheres to legislative requirements and standards. When contemplating a renovation, it’s a good opportunity for the licensee to ensure that the entire licensed pharmacy space complies with all pharmacy legislation. To ensure compliance, ACP will be assessing the entire pharmacy throughout the renovation process (not just the area being renovated).

When are renovations required?

Proprietors and licensees may choose to apply to renovate their pharmacy at any time to meet the needs of pharmacy staff and patients.

Renovations may also be required due to

• changes in standards or legislation, or
• direction from ACP pharmacy practice consultants.

Required steps

For any renovation, the licensee must follow the process detailed below.

Step 1: Planning your renovation

1. Understand the legislation: ACP has developed the Foundational requirement guidelines for opening and operating a licensed pharmacy as a tool to help licensees ensure they meet legislated requirements.
2. Prepare a floorplan: The floorplan must include the entire licensed space, including the area that you are proposing to renovate. Refer to the Floorplan requirements guide for details.
3. Staff and training planning: The licensee must consider how the renovation will affect pharmacy operations and the professional services the pharmacy team intends to offer.
   • For example, if a pharmacy proposes a renovation to add sterile compounding services, the licensee must demonstrate that the regulated members are trained in sterile compounding and assign a qualified compounding supervisor before submitting a renovation application.
4. Additional considerations: Depending on your pharmacy and the renovation you are planning, there may be additional factors to consider.
   • Shared premises: Does the pharmacy share a space with another business or healthcare professional? The pharmacy and the adjoining business must be able to operate independently of one another.
   • Lock and leave: If the pharmacy is a shared premise or has different hours than the larger business enterprise, it must operate as a lock and leave pharmacy.
   • Compounding: If the pharmacy offers compounding services, the pharmacy must meet additional requirements and standards for non-sterile compounding or sterile compounding.
     • Please ensure you and your team have a thorough understanding of all compounding standards including facility, equipment, personnel, training, policies and procedures, and quality assurance requirements before submitting a renovation application. The proposed changes to the pharmacy must not be implemented until all inspection findings have been resolved and the inspection is concluded.
   • Licence category: Do you need to change the pharmacy licence category?
     • A compounding and repackaging licence is required if the pharmacy will be selling compounded preparations or repackaged drugs to another pharmacy.

Step 2: Submitting the renovation application in myACP

The licensee must submit an application to renovate the pharmacy in myACP by completing the following steps.

1. Complete the application and upload all supporting documentation (must be in PDF format).
   • Floor plan (required): The floor plan must accurately depict the physical facilities, intended use of space, and layout of the entire licensed pharmacy. The floor plan must comply with the Floor plan requirements guide. Any submissions that do not comply with this guide will be rejected.
   • Shared premises form (only required if the pharmacy shares premises with another business): You must also provide an additional floorplan depicting the overall facilities, space, and layout of the entire premises.
   • Sterile floor plan preliminary questionnaire (only required if adding sterile compounding): You must submit this completed questionnaire if the renovation of the pharmacy includes adding sterile compounding.
2. Provide payment.
   • Once you submit your application, you will be required to provide payment. The college’s fees are outlined in the ACP fee schedule. Only Visa, Visa Debit, Mastercard, or Debit Mastercard will be accepted.

Your application is not complete and will not be reviewed until the application, all supporting documentation (including a complete floor plan that adheres to the floorplan requirements guide), and payment have been submitted.

NOTE: Applications are reviewed in the order in which they are submitted. Insufficient floor plans or incomplete applications often result in a delay in the review of your application and may result in refusal of your renovation application.

Step 3: Application review and decision

1. Initial review: ACP will conduct an initial review of your application and respond back to you with additional questions within 15 business days of receiving a complete application.
   • ACP will complete a thorough review of the floorplan of the entire licensed pharmacy, including the areas of the pharmacy that are being renovated.
   • If the pharmacy is conducting sterile renovations, the pharmacy practice consultant will reach out to the licensee for additional clarification.
2. Application decision
   • Conditional acceptance: If the proposed floorplan of the entire pharmacy meets all requirements and all supporting documentation is sufficient, ACP may conditionally accept the renovation application and you are expected to proceed with renovating the pharmacy in accordance with the submitted floor plan within six months. Note that conditional acceptance
     • is based on the final version of the floorplan submitted,
     • is valid for six months from the date it was accepted, and
     • does not guarantee that your renovation will pass the final inspection.
   • Refusal: If the floor plan or supporting documentation do not meet all legislative requirements, the supporting documentation is not sufficient, or the renovation application has been open for more than six months, the renovation application may be refused. 

NOTE: Ensure your application is submitted at least 45 days before construction begins. You will receive acknowledgement of your application or follow-up questions within 15 days, but the duration of the approval process will depend on the floor plan meeting all foundational requirements.

Step 4: Complete your renovations

1. Begin construction: The renovation construction may begin once the renovation application has been conditionally accepted.
   • You are expected to complete the renovation within six months of conditional acceptance.
   • If construction has been delayed or you are not able to complete the renovation within six months, you must contact ACP. The application may be cancelled and, in this case, you will need to submit a new application to renovate.
   • If there are any changes to the floorplan, you must consult ACP. The outcome of the final inspection may be affected if changes are made during renovation that were not reflected in the proposed floorplan. The application may be cancelled and, in this case, you will need to submit a new application to renovate.

Step 5: Renovation inspection

1. Submit the Pharmacy inspection readiness form: After the renovation is complete, submit the form to schedule the required inspection. A pharmacy practice consultant will attempt to schedule an inspection of the pharmacy within one month.
2. Prepare for the inspection: During the inspection, the pharmacy practice consultant will inspect the entire pharmacy space, including the renovated area, to ensure that the pharmacy meets the Standards for the Operation of Licensed Pharmacies, other applicable standards, and foundational requirements. Ensure you review and meet all elements as indicated in the Pharmacy inspection compliance checklist.
   • Once the onsite inspection is completed by the pharmacy practice consultant, inspection findings will be communicated through myACP and all inspection findings must be resolved in a specified time period. Inspection findings may include the pharmacy requiring further changes or may require a new renovation application.