Cars queue up at the state’s first rapid Covid-19 testing center in New Haven April 17, 2020. The site which is run by CVS Health and the state of Connecticut opened Friday and provides results within about 30 minutes using a rapid test made by Abbott Laboratories free of charge for those who meet federal criteria and register in advance. The center, located in the parking lot at the former Gateway Community College campus on Sargent Drive, will be open seven days a week and expects to test up to 750 people a day. Cloe Poisson /
Cars queue up at the state’s first rapid Covid-19 testing center in New Haven April 17, 2020, run by CVS Health and the state of Connecticut. In February at a CVS in Waterford, a number of New Yorkers improperly received vaccinations, documents show. Cloe Poisson /

By the time state officials arrived at a Waterford CVS on Feb. 4 to investigate reports that New Yorkers were getting the COVID-19 vaccine, the pharmacy had already vaccinated more residents from the neighboring state than it had from Connecticut, according to state Department of Public Health documents.

The documents show that DPH officials were warned about the steady stream of New York license plates in the parking lot three days before they visited the Boston Post Road pharmacy. That visit made the news, largely because Waterford police were called in when some New York residents refused to leave the line, insisting they had done nothing wrong and had already spent $150 to take the ferry over to Connecticut to get their shots.

After hearing about the developing situation on Feb. 4, Barbara Cass, chief of health care quality and safety for the DPH, wrote an email that day to DPH Chief of Staff Adelita Orefice.

“Michelle [Gilman, the state’s deputy chief operating officer) called Tony [Bruno, the DPH vaccine site inspector who was at the Waterford pharmacy that day] and suggested they pull people out of the line. I have asked them to speak with the manager who should be doing that,” Cass wrote in the email. “The last thing I want is them being arrested or worse assaulted. Michelle wanted it elevated to you quickly,” added Cass.

No one was arrested, however, and when Gov. Ned Lamont was asked about the incident during his afternoon press conference that day, he put the onus on the out-of-state residents who got “caught” — not on CVS — saying, “You’ve got to live here in Connecticut or work here in Connecticut, you’ve got to identify yourself as such when you sign on to … that CVS site.”

But emails and documents obtained through a Freedom of Information request show that town officials, the local health director and a state representative had called DPH several times in the days preceding Feb. 4 about the line of New Yorkers pulling into the Waterford CVS and that there had been additional complaints about who was getting vaccinated through at least one other CVS location.

Records show that as of Feb. 4, the day Bruno walked into the store, 318 people with New York addresses had been vaccinated at the Waterford CVS, compared to 301 Connecticut residents. Residents from 10 other states had also been vaccinated there.

The majority of the out-of-state residents who had received a vaccine had taken advantage of an apparent glitch in the CVS computer system that allowed them to sign up for vaccines in Connecticut, even though they didn’t live here.

In addition, many of them were not only from the wrong state but also were in a group not eligible for the vaccine at that time. The majority of the New Yorkers, for example, were between 65 and 74 years old when only people over 75 were eligible on that date, state records show.

“CVS and Walgreens has been told numerous times about the complaints that we are getting,” DPH epidemiologist Deepa Mavani wrote in an email to Benjamin Bechtolsheim, the state’s vaccine coordinator the day before DPH investigators went to Waterford. “We have asked them to reinforce that they only vaccinate people who live or work in CT.”

The first warning 

The first person to notify state officials that there was a problem at the CVS was Ledge Light Health District Director Stephen Mansfield, whose district includes Waterford.

In a Feb. 1 email to Bechtolsheim and others, Mansfield told them Waterford First Selectman Rob Brule had been fielding complaints about who was getting vaccinated at the CVS on Boston Post Road.

“Good morning Nancy [Sharova, DPH’s Health Program Supervisor] and Benjamin, it has been reported to me that the CVS in Waterford is vaccinating out-of-state residents,” Mansfield wrote. “It is my understanding that vaccine in Connecticut is only available to those who live or work in Connecticut. Can you confirm? And is there anything that can be done about this?”

Bechtolsheim told Mansfield that they would look into it and promised to get back to him. The next day, Mansfield sent Bechtolsheim a photo of several cars with New York license plates parked at the CVS and asked, “Has someone contacted CVS to determine exactly who they are vaccinating? And if they are vaccinating out-of-state individuals, is there going to be any enforcement action?”

The situation escalated to the attention of Gilman, the DPH’s deputy chief operating officer, that same day, when Sen. Heather Somers, R-Groton, emailed Bechtolsheim.

“I have been informed by a clinician that CVS in Waterford is providing vaccines regardless of age or residence,” Somers wrote. “People are taking the Long Island ferry to CT to obtain the vaccine. I can put you in touch with the clinician if you need.”

Bechtolsheim forwarded Somers’ email to Gilman and Orefice, the DPH chief of staff, asking, “Shall we escalate this to CVS or what is the current dialogue on this questions? Lita – shall we have someone go by the store to do a compliance visit/audit? I don’t think it’s a policy issue – it’s a practice one.”

Glitch in the system

While state officials were pondering on Feb. 4 whether to send investigators to Waterford, Isa Eliasoph and her husband were getting on the ferry from Long Island to New London to get their first dose of the Pfizer vaccine, six days after she had been allowed to schedule their shots online from her Great Neck home.

“I entered my home ZIP code. No availability. The CVS site prompted me to try different ZIP codes. After several tries, I finally typed in the ZIP code for Montauk Point. I was amazed to find myself invited to schedule appointments on February 4th – this past Tuesday – in Waterford,” Eliasoph wrote in an email to Mansfield about a week later. She contacted Mansfield because of concerns she wouldn’t be able to get her second dose at the Waterford CVS.

“As the crow flies, Montauk NY is directly south of Waterford CT. I entered all of the required information — our names, DOBs, address, email addresses, cell phone #s, Medicare #s,” Eliasoph wrote. “Our appointments were confirmed and appointments for our second doses were automatically scheduled for February 23rd.”

The Eliasophs got their first doses on Feb. 4, barely missing Bruno and another DPH inspector who arrived at the Waterford location that same afternoon and found 10 people from Long Island in line to get vaccinated. None of them were first responders or over 75 — the only people eligible to be vaccinated in Connecticut at that point.

In interviews with DPH investigators, the New Yorkers said they just put their home addresses into the CVS system, were offered appointments at the Waterford store and took them.

The New York residents at first refused to get out of line, “indicating they had done nothing wrong and that the vaccine had already been designated for them,” according to a DPH incident report. That’s when the Waterford police were called, although it is unclear by whom. CVS officials said at the time they didn’t call the police, and Waterford police said they didn’t have a police report on the incident.

No one was arrested, however, and eventually the New Yorkers left without incident.

CVS employees told Bruno they had been vaccinating Connecticut residents over 75 and New York residents over 65 since they began offering the shots on Jan. 25, according to DPH’s incident report. The Waterford pharmacy was one of only two CVS stores in Connecticut offering vaccines at that time. CVS and Walgreens expanded their vaccination sites the very next week, when the federal government announced it would begin shipping vaccine to them.

Gilman and Orefice asked DPH officials to analyze vaccine data to see what was going on at that store and other CVS locations. The next day, state officials realized more New Yorkers than Connecticut residents had been vaccinated in Waterford.

“I looked at this quickly. NY numbers larger than CT? Appears so,” Orefice wrote in an email to Gifford. “We can get an analysis.”

State officials were about to find out the problem was not isolated to just one store in Waterford.

Second dose issues

A few days after the Waterford incident, DPH officials received an email from a Massachusetts woman complaining that she couldn’t get a second dose appointment for her 80-year-old husband at the Connecticut CVS where he had already been vaccinated.

DPH employee Natalie Anderson summarized the Massachusetts woman’s plight in an email to Mavani, the DPH epidemiologist.

“An 80 year old patient that lives in MA was told by CVS in MA that they didn’t have any appointments and was directed by CVS to the CT location which was the closest to the patient,” Anderson wrote.

“The patient does not live or work in CT, but received first dose. Now, they cannot schedule a second dose in CT as they are ineligible due to out of state residency; however, when the patient tries to schedule in MA, they are being told they cannot receive the second dose as MA is currently administering only first doses.”

The email does not identify the woman’s Massachusetts address or at which CVS her husband received his first dose.

But the communication crystallized an issue that DPH officials were trying to resolve with CVS — how to get the hundreds of people who were wrongly vaccinated in Connecticut their required second doses.

It was a question that Eliasoph, the Long Island resident, was posing also to Ledge Light Health District’s director, hoping he could help them get a second dose. However, Ledge Light was only administering the Moderna vaccine, so Mansfield forwarded the problem to Bechtolsheim.

True problem at CVS

“I learned this morning that New Yorkers who had appointments to be vaccinated in Waterford were turned away yesterday because they don’t live in Connecticut,” Eliasoph wrote to Mansfield. “I understand why those people were turned away. I also realize that my husband and I were likely vaccinated in Waterford because of a glitch in the CVS system. We each need a second dose of the Pfizer vaccine and aren’t sure where to find it.”

Eliasoph said she called the CVS in Waterford “hoping to learn that our second dose appointments would be honored. I received no such reassurance.”

“I was told to call the [New York State] Dept. of Health. I was told that CVS was in negotiations with the NYS and CT Departments of Health to figure out a solution to this problem — because a number of New Yorkers are in this situation,” she said.

Meanwhile, CVS officials were also trying to clarify with DPH officials what they should do.

In a series of emails, CVS Health Government Affairs Director Maggie Moree asked Connecticut  officials for direction. DPH had put out a bulletin only a few days before the Waterford incident telling vaccinators to offer second doses to people even if they had been inadvertently vaccinated in the wrong category.

During the initial vaccine rollout, the state had used phases, starting with health care workers and first responders, and then moving to anyone over 75. Many teachers from various age groups had also been vaccinated.

In an email, Moree said that CVS officials assumed the out-of-state residents would fall in that category and just get their second doses in Connecticut, but state officials had other ideas.

“We are asking CVS pharmacies that scheduled out of state/ineligible recipients in error to find a second dose in the person’s state of residence,” DPH’s Immunization Program Manager Kathy Kudish wrote to Moree on Feb. 16, nearly two weeks after the Waterford incident.

Moree asked for more clarification in her response to Kudish.

“So I am clear and we don’t end up with police being called to Waterford – CVS is being asked not to honor any second dose appointments where first doses were given to individuals who may not have met the state’s eligibility criteria (live or work in CT and in one of those categories of eligibility)?” Moree said.

Kudish confirmed the policy in her second email.

“A clarifying point: CVS is being asked not to honor any second dose appointments where first doses were given to individuals who are 65+ but who do not live in CT,” Kudish wrote back.

“Our understanding is that this was the true problem at the CVS locations (out of state older people),” Kudish added.

CVS spokeswoman Tara Burke said Thursday all of the out-of-state residents who got their first doses at the Waterford CVS got their second doses at pharmacies in their home states.

“We worked directly with the impacted patients to ensure they were vaccinated per their state guidelines,” Burke said.

She added that CVS also changed its vaccine website to avoid similar errors.

“We updated our site so that customers must affirm they meet the eligibility requirements in the state where the pharmacy they are booking their appointment is located,” Burke said.

DPH didn’t conduct any vaccination analysis for any CVS location other than pulling the data for the Waterford site, because they believed the problem was isolated to that store, even though they knew about the Massachusetts man who got vaccinated at the Connecticut CVS store.

“This analysis was tied solely and specifically to the incident at the Waterford CVS,” DPH spokeswoman Maura Fitzgerald said. “DPH did not receive complaints alleging widespread vaccination for out of state individuals at CVS locations other than the CVS/Waterford site.”

Dave does in-depth investigative reporting for CT Mirror. His work focuses on government accountability including financial oversight, abuse of power, corruption, safety monitoring, and compliance with law. Before joining CT Mirror Altimari spent 23 years at the Hartford Courant breaking some of the state’s biggest, most impactful investigative stories.

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