Timeframe for the Administration of Medications

What is the timeframe within which medications need to be administered, i.e., a medication is ordered to be given daily at 8 am. Does the nurse need to administer the medication within 30 minutes before or after; or 60 min before or after; or is there another timeframe?

CMS Conditions of Participation state, under Survey Procedures, that the hospital shall be surveyed in regard to medication administration within 30 minutes of the scheduled time for administration.

CMS regulations state:


§482.23(c)(1) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.

Survey Procedures §482.23(c)(1)

Verify that there is an effective method for the administration of drugs. Use the following indicators for assessing drug administration:

  • Verify that there are policies and procedures approved by the medical staff covering who is authorized to administer medications, and that the policies are followed.
  • Review a sample of medication administration records to see that they conform with the practitioner's order, that the order is current, and that drug and dosage are correct and administered as ordered. 
  • Observe the preparation of drugs and their administration to patients in order to verify that procedures are being followed. Are patients addressed by name and/or identiband checked? Does the nurse remain with the patient until medication is taken? Are drugs administered within 30 minutes of the scheduled time for administration? 
  • Verify that nursing or other personnel authorized by medical staff policy to administer drugs have completed appropriate training courses or are licensed or authorized to do so by State law and function under supervision as necessary. 
  • Check the QAPI activities to see if the administration of drugs is regularly monitored. The monitoring should include reports of medication irregularities or errors, their nature, frequency and the corrective action taken. 
  • Interview supervisory nursing personnel to determine how supervision is provided. Also interview personnel who administer medication to verify that the supervision is, in fact, provided. 
  • Are personnel other than nursing personnel administering drugs or biologicals? If yes, determine if those personnel are administering drugs or biologicals in accordance with Federal and State laws and regulations. Use the above procedures to determine compliance. 

The Joint Commission does not state a specific timeframe for the administration of medications.  Standard MM.5.10, EP5 states that qualified individuals administering medications must verify that the medication(s) is being administered at the proper time, in the prescribed dose and the correct route. 

You should also check your state regulations regarding the timeframe for the administration of medications.

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