Texas HSC Chapter 331
The September 1, 2024 Chapter 331 Compliance Deadline
Texas HSC Chapter 331 took effect September 1, 2024. Here is exactly what covered facilities had to have in place by that date — and how to verify you are still compliant.
Texas Health & Safety Code Chapter 331, enacted by SB 240 (88th Legislature, 2023), took effect September 1, 2024. By that date, every covered Texas healthcare facility was expected to have a written workplace violence prevention plan adopted, a committee seated, and the program operating. The deadline has passed — which means compliance is no longer a project with a due date but an active obligation a surveyor can check at any licensure survey.
This article lays out exactly what had to be in place by September 1, 2024, why the passed deadline raises rather than lowers the stakes, and how to verify your facility is still compliant today. For the full statutory scope, see Texas SB 240 explained. The pillar is Texas SB 240 & HSC Chapter 331 compliance.
#The date, stated plainly
SB 240 was signed in the 2023 legislative session and created Chapter 331 of the Health & Safety Code. Its operative provisions became effective September 1, 2024 (Texas HSC Chapter 331; SB 240, 88th Leg., 2023). For hospitals, the Texas Health and Human Services Commission adopted the implementing rule 26 TAC §133.55 in the Texas Register on October 11, 2024, hard-wiring the statute into the hospital licensure-survey framework.
The practical reading: the law became enforceable on September 1, 2024, and the hospital rule that surveyors apply followed shortly after. A facility that treated the deadline as aspirational is now operating out of compliance every day the program is absent.
#What had to be in place by the deadline
By September 1, 2024, a covered facility was expected to have the core program elements established and functioning — not merely planned. The checklist below is the one a surveyor effectively works through:
| Required element | What "in place" means |
|---|---|
| Written WVP plan | A facility-specific plan adopted by the facility, not a generic template, addressing the facility's own hazards and units |
| WVP committee | A standing committee seated with the statutorily required membership and a meeting cadence |
| Confidential reporting | A mechanism for staff to report incidents, with confidentiality protections |
| Anti-retaliation | Policy language protecting staff who report or who decline to provide care in a dangerous situation, where applicable |
| Post-incident response | Procedures for treatment access and work-assignment adjustment after an incident |
| Annual evaluation | The cycle of reviewing the plan and reporting to the governing body, begun in the first year |
Each of these is detailed in the Chapter 331 requirements overview. The point for the deadline is that all of them were due — a facility that adopted a plan but never seated a committee, or seated a committee but never ran a post-incident procedure, was only partially compliant on day one.
#Who the deadline applied to
Chapter 331 reaches a broad set of facility classes — hospitals, nursing facilities, ambulatory surgical centers, freestanding emergency medical care facilities, and home and community support services agencies (HCSSAs) meeting the employed-RN threshold, among others. If you are unsure whether your facility was covered as of September 1, 2024, work through the coverage decision guide. For hospitals specifically, 26 TAC §133.55 is the rule a surveyor cites; for home health and hospice, HHSC Provider Letter PL 2024-10 carries the parallel expectations.
The deadline was uniform: the statute did not phase in obligations by facility size or wait for the implementing rules to publish. Covered facilities were expected to comply from the effective date.
#Why a passed deadline raises the stakes
It is tempting to treat a past deadline as water under the bridge. The opposite is true. Before September 1, 2024, a facility building its program was early. After it, a facility without a program is non-compliant — and the exposure is now live:
- A surveyor can check it today. Compliance is verified at licensure and re-licensure surveys against 26 TAC §133.55. A gap is documented as a statement of deficiencies requiring a plan of correction.
- There is no grace period to point to. The effective date is in the past, so "we were getting to it" is not a defense at survey.
- Discovery dates your program. After a serious incident, litigation discovery asks not only whether you had a plan, but when you adopted it. A program dated well after the statutory effective date is a harder fact to explain than one dated on time.
Note what is not on this list: a fine. Chapter 331 has no dedicated penalty schedule, which is exactly why some operators underestimated the deadline. The real consequences — a licensure deficiency and litigation exposure — do not need a fine to bite.
#How to verify you are still compliant
The deadline is not a one-time checkbox; it opened a continuing obligation. Use these steps to confirm your program is current:
- Confirm the plan exists and is facility-specific. A template with another facility's name in the header does not count. The plan must address your hazards, your units, and your controls.
- Confirm the committee is seated and meeting. Check the appointment records and the minutes. A committee that was named once and never convened will not survive a tracer.
- Confirm the recurring elements are running. Training touchpoints, incident tracking, the post-incident procedure, and the annual plan evaluation to the governing body should each have a documented trail since the program began.
- Date each element. Be able to show when the plan was adopted, when the committee was seated, and when the first annual evaluation occurred. This is what answers the "and when did you do this?" question at survey and in discovery.
The annual plan evaluation to the governing body is the mechanism that keeps a deadline-driven program alive year after year — it converts a one-time launch into a documented, living program.
#What to do if you are behind
If your facility missed the deadline or built only part of the program, the answer is not to backdate anything — it is to build the program now and document honestly when each element went into place:
- Score the gap with a survey-readiness audit: a scored report against the Chapter 331, 26 TAC §133.55, and PL 2024-10 checklist so you know precisely what is missing.
- Stand up the program through a workplace violence prevention program: the facility-specific plan, the seated committee, training, reporting and post-incident policies, and the survey-readiness binder.
- Keep it current with annual program reviews so the evidence is always survey-ready, not reconstructed under pressure.
For a self-guided start, the Chapter 331 compliance checklist maps each requirement to where its evidence should live.
The September 1, 2024 deadline did not close a window — it opened an obligation that a surveyor can test on any survey day. The facilities that are ready are the ones that can show not just that they comply, but since when.
Sources: Texas Health & Safety Code Chapter 331 (SB 240, 88th Leg., 2023; effective September 1, 2024); 26 TAC §133.55 (adopted Oct. 11, 2024); HHSC Provider Letter PL 2024-10. This article is general compliance information, not legal advice.