Program & Plan Development
The Annual WVP Plan Evaluation, Step by Step
Chapter 331 requires an annual WVP plan evaluation reported to your governing body. Here is a repeatable process — and the board-ready report it produces — that satisfies the statute.
The annual WVP plan evaluation is Chapter 331's built-in recurring obligation: the workplace violence prevention committee must evaluate the facility's plan at least annually and report the results to the governing body. It is the single requirement that renews by statute every year — and the documented evaluation, plus proof it reached the board, is what proves your program is alive rather than archived.
Most facilities pass the first survey on the strength of a freshly built program. The annual evaluation is what keeps them passing the second and third. This is the process that makes it repeatable.
#What the statute requires
Texas Health & Safety Code Chapter 331 (added by SB 240, 88th Legislature, 2023) requires the WVP committee to meet at least annually to evaluate the plan and report the results to the facility's governing body. Two distinct obligations live inside that sentence:
- The evaluation itself — a substantive committee review of whether the plan is working.
- The report to the governing body — a separately documented step proving the board received it.
Surveyors check for both, and the second is the one facilities most often miss. An evaluation done but never reported to the governing body is a frequently cited deficiency, because the board-reporting step is its own statutory requirement. The hospital rule 26 TAC §133.55 (adopted in the Texas Register, Oct. 11, 2024) hard-wires this into the licensure survey.
The recurring nature is the point. The annual evaluation, the annual worksite analysis and training the Joint Commission expects (effective Jan. 1, 2022 for hospitals), and OSHA's periodic program evaluation under Publication 3148 all renew the obligation every year. The program is never "done."
#A repeatable five-step process
Treat the evaluation as a defined annual procedure, not an ad hoc meeting. The same five steps run every year.
#Step 1 — Assemble the evidence
Before the committee meets, gather the year's record:
- The incident log and trend report — what happened, where it concentrated, what direction it is moving.
- The worksite analysis and mitigation log — which findings closed, which remain open.
- Training compliance — rosters reconciled against the full employee and contracted-staff census.
- Corrective-action status — what the committee committed to last year and whether it closed.
- Any regulatory changes to Chapter 331, 26 TAC §133.55, PL 2024-10, the Joint Commission standards, or OSHA guidance.
#Step 2 — Evaluate the plan against the evidence
The committee asks the questions a surveyor would ask:
- Did the plan's prevention controls match where incidents actually occurred?
- Were worksite-analysis findings followed to closure?
- Did training reach everyone, on cadence, including contracted staff?
- Did the post-incident response run every time it was needed?
- Does the plan still reflect actual floor practice, or has the facility drifted?
#Step 3 — Document findings and decisions
Capture the evaluation in committee minutes that record what was reviewed, what the committee concluded, and what it decided to change. This closing of the loop — showing that data drove a program change — is exactly what the Joint Commission's tracking-and-trending requirement tests.
#Step 4 — Produce the board-ready report
Translate the evaluation into a concise governing-body report. It should state, in executive language: the year's incident trend, the status of corrective actions, training compliance, plan revisions made, and the committee's recommendations. This is the artifact that satisfies the board-reporting obligation — and the one surveyors ask to see.
#Step 5 — Report to the governing body and capture proof
Deliver the report to the board and capture the proof: board minutes referencing the WVP evaluation, or a signed acknowledgment. Without this evidence, the evaluation is unprovable no matter how thorough it was.
#What the evaluation produces
| Output | Where it lives | Why it matters |
|---|---|---|
| Evaluation minutes | Committee minutes tab of the binder | Proves the committee evaluated the plan |
| Updated plan version | Plan tab; version-control block | Shows the program responds to its own data |
| Closed corrective actions | Mitigation log | Demonstrates findings reach closure |
| Board-ready report | Annual evaluation tab | Satisfies the governing-body obligation |
| Board minutes / signed report | Annual evaluation tab | Proves the report reached the board |
These outputs flow directly into the survey-readiness binder at the annual-evaluation tab — the tab surveyors open to confirm the program is current.
#Common deficiencies
| Deficiency | Why it's cited |
|---|---|
| Evaluation done but never reported to the governing body | Board reporting is a distinct statutory obligation |
| No minutes proving the committee evaluated the plan | Without minutes the evaluation is unprovable |
| Evaluation is a formality with no plan changes | "Evaluate" implies acting on findings, not rubber-stamping |
| No proof the board received the report | Board minutes or a signed report are required evidence |
| Evaluation lapses past the 12-month mark | "At least annually" is a hard cadence |
#Making it sustainable
The annual evaluation is only as reliable as the committee that runs it and the cadence that carries it. A committee that meets quarterly and minutes its work arrives at the annual evaluation with the evidence already assembled — which is why a functioning committee makes the evaluation almost automatic. See our guide to standing up a WVP committee that functions.
Because the obligation renews by law every year, the evaluation belongs inside a maintained WVP program of record that puts it on the calendar and never lets it lapse. VIGILO runs the annual plan evaluation and produces the governing-body report through the annual program reviews subscription, converting the statute's annual obligation into a managed, recurring deliverable. A focused survey-readiness audit can confirm whether your last evaluation would survive a tracer.
For the statutory text, see the HSC Chapter 331 requirements page.
Primary sources: Texas Health & Safety Code Chapter 331 (SB 240, 2023); 26 TAC §133.55 (Texas Register, Oct. 11, 2024); The Joint Commission workplace violence prevention requirements (EC/HR/LD, effective Jan. 1, 2022 for hospitals); OSHA Publication 3148.