Texas HSC Chapter 331
The Chapter 331 Annual Plan Evaluation, Explained
Texas HSC Chapter 331 requires the WVP committee to evaluate the plan at least annually and report the results to the governing body. Here is what that recurring obligation involves.
Under Texas HSC Chapter 331, the workplace violence prevention committee must evaluate the WVP plan at least annually and report the results to the facility's governing body. This is a recurring statutory obligation — not a one-time filing — and the board-reporting step is one of the most frequently missed requirements at a licensure survey.
The annual plan evaluation is what makes Chapter 331 a living program rather than a binder you assemble once and forget. This article explains what the evaluation must cover, why the governing-body report is a distinct obligation, and the documentation a surveyor opens to confirm both happened. For the full statute, see Texas SB 240 explained; for the committee that performs the evaluation, see who must serve on a Chapter 331 committee. The pillar is Texas SB 240 & HSC Chapter 331 compliance.
#What the statute requires
Chapter 331's sixth program element reads, in substance: the committee meets at least annually to evaluate the plan and reports the results to the governing body (Texas HSC Chapter 331; SB 240, 88th Leg., 2023). Two separate actions are embedded here:
- The evaluation — a substantive committee review of whether the plan is working.
- The report to the governing body — delivery of that evaluation's results to the board.
Facilities routinely do the first and forget the second, or push the report only to a department head. The statute names the governing body specifically. A safety-committee write-up that never reaches the board does not satisfy the requirement.
#Why this is the obligation that defines the program
Because the evaluation and board report renew every twelve months, Chapter 331 is structurally a program of record, not a one-time project. A plan adopted in 2024 and never re-evaluated is, by the statute's own terms, out of compliance the following year — regardless of how good the original plan was.
This recurring cadence is also why the annual evaluation is the natural anchor for an ongoing compliance relationship. The same logic appears across the regimes a Texas hospital answers to: the Joint Commission expects an annual worksite analysis and annual training, and OSHA's voluntary framework includes periodic program evaluation. One annual rhythm can satisfy all three.
#What the evaluation should cover
The statute requires an evaluation but does not prescribe a rigid template. A defensible annual evaluation typically reviews:
| Review area | What the committee examines |
|---|---|
| Incident data | The year's reported incidents, trends, and whether the data drove any program change. |
| Worksite analysis findings | Open and closed corrective actions from the facility's risk assessment. |
| Training completion | Whether applicable staff — including contracted and per-diem — completed annual training. |
| Policy currency | Whether the plan, reporting policy, and post-incident process still match floor practice. |
| Committee activity | That the committee met and acted across the year. |
| Recommended changes | Specific revisions to the plan for the coming year. |
The output is a written evaluation the committee can present, and from which the governing-body report is drawn.
#The governing-body report
The report to the board is the step that produces the surveyor-checkable evidence. It does not need to be elaborate, but it must exist and be traceable. A compliant board report:
- States that the committee evaluated the plan in the trailing twelve months.
- Summarizes the findings and any recommended changes.
- Is delivered to the governing body — with proof.
That proof is usually board minutes reflecting receipt of the report, a signed report acknowledged by the board, or both. Without one of these, the facility cannot demonstrate the obligation ran, even if the committee genuinely did the work.
#What a surveyor reviews
A Texas HHSC licensing surveyor verifies the annual evaluation through the paper trail:
- Committee minutes showing the plan was evaluated within the last twelve months.
- The annual evaluation record itself.
- Governing-body minutes or a signed report proving the results reached the board.
The signature finding in this area is "evaluation done, never reported to the governing body." The board-reporting step is a distinct statutory obligation, and its absence is citable even when the evaluation was thorough. A related finding is no minutes at all — without minutes, neither the evaluation nor the report is provable.
#How to make it repeatable
- Put the evaluation on the calendar as a fixed annual committee agenda item, dated so it never drifts past twelve months.
- Make the governing-body report a standing board agenda item, so delivery is routine and minuted.
- Keep the paper trail — committee minutes, the written evaluation, and board minutes or a signed report — in the survey-readiness binder.
- Tie the evaluation to live data — incident trends, worksite-analysis closures, training completion — so it is substantive rather than perfunctory.
Facilities that want this run for them use our annual program reviews subscription, which performs the annual plan evaluation, prepares the governing-body report, and keeps the committee minutes and survey-readiness file current between surveys — converting the statute's annual obligation into a managed program of record. To self-assess first, the Chapter 331 compliance checklist includes the evaluation and board-report line items, and a survey-readiness audit scores whether your evidence would hold up.
The annual evaluation is short work when it is structured and calendared — and a recurring liability when it is left to memory. Because it renews by statute every year, building it as a fixed rhythm is what keeps a facility continuously survey-ready. And because Chapter 331 carries no fine schedule, this recurring evidence is precisely what protects a facility when a survey or an incident arrives.
Sources: Texas Health & Safety Code Chapter 331 (SB 240, 88th Leg., 2023); 26 TAC §133.55; HHSC Provider Letter PL 2024-10. This article is general compliance information, not legal advice.