Texas HSC Chapter 331
Who Must Serve on a Chapter 331 WVP Committee
Texas HSC Chapter 331 requires a workplace violence prevention committee with specific members — an RN providing direct care, and a physician and security-services employee if employed.
Texas HSC Chapter 331 requires a workplace violence prevention committee that must include a registered nurse who provides direct patient care. It must also include a physician who provides direct patient care if the facility employs any, and a security-services employee if the facility employs any. The committee may be an existing committee the facility re-authorizes.
The committee is the governance engine of a Chapter 331 program — it owns the plan, reviews incident data, and delivers the annual evaluation to the board. Getting its composition right is a frequent point of failure at survey. This article details who must serve, how the conditional seats work, and what documentation a surveyor opens to verify it. For the full statute, see Texas SB 240 explained and our pillar, Texas SB 240 & HSC Chapter 331 compliance.
#The required membership
Chapter 331 names three member categories. One is mandatory; two are conditional on whether the facility employs people in those roles.
| Member category | Required? | The condition |
|---|---|---|
| Registered nurse providing direct patient care | Mandatory | Every covered facility must seat an RN who provides direct care. |
| Physician providing direct patient care | Conditional | Required only if the facility employs any physicians. |
| Security-services employee | Conditional | Required only if the facility employs any security-services personnel. |
(Source: Texas HSC Chapter 331; SB 240, 88th Leg., 2023.)
#The RN-providing-direct-care seat is non-negotiable
This is the seat surveyors check first, and the one most often missing or mis-filled. The statute is specific: a registered nurse who provides direct patient care — not a nurse executive who left the floor years ago, not a quality director with an RN license who no longer treats patients. The point is to keep a frontline clinical voice on the committee that shapes the plan. Document the member's role so it is clear the person actually provides direct care.
#The physician seat is conditional on employment
A physician who provides direct patient care must serve if the facility employs any physicians. Many hospitals work primarily with independent or contracted physicians rather than employed ones; if a facility employs no physicians, the seat is not required. The distinction a surveyor draws is employment, so be prepared to show your physician employment status if you do not seat one.
#The security-services seat is conditional on employment
Likewise, a security-services employee must serve if the facility employs any. This is the one place "security" appears in Chapter 331's committee rule, and it is strictly a committee-membership requirement — it does not turn the WVP program into a guarding operation. If a facility contracts its security function rather than employing it, the seat may not be required; document the arrangement either way.
A note on scope: the security-services seat is about having an environment-of-care perspective at the table, not about staffing guards. A compliant WVP program is a documentation and preparedness program, not a private-security service.
#You can re-authorize an existing committee
Chapter 331 does not force you to create a brand-new body. A facility may designate an existing committee — an environment-of-care committee, a safety committee, or similar — to serve as the WVP committee, provided it is formally authorized for that purpose and includes the required member categories.
If you take this route, the paper trail matters. A surveyor will want to see:
- A charter or authorizing resolution that explicitly assigns the WVP function to the committee.
- A membership roster that maps each person to a required category (and your RN's direct-care role).
- Appointment documentation for the named members.
#What a surveyor reviews
A Texas HHSC licensing surveyor verifies committee composition through documents, not assertions. The records they open:
- The committee charter / authorization naming the WVP function.
- The membership roster, with each required category accounted for.
- Appointment letters for the RN, and for the physician and security-services member where required.
- Meeting minutes for the trailing twelve months, proving the committee actually convenes and acts.
The most common committee deficiencies are a missing required member category (the RN-direct-care seat most often) and no minutes proving the committee meets. A committee that exists on paper but never convenes cannot demonstrate the annual evaluation, which is itself a statutory obligation — see the Chapter 331 annual plan evaluation.
#How to stand the committee up correctly
- Confirm your conditional seats. Determine whether you employ physicians and security-services personnel; document the answer either way.
- Seat a true direct-care RN and capture their direct-care role in the appointment record.
- Charter the committee — new or re-authorized — with an explicit WVP mandate.
- Issue appointment letters for each required member.
- Set a meeting cadence and minute every session, so the trailing-twelve-months record always exists.
Facilities that want this done turnkey use our policy and plan development service, which drafts the committee charter and Chapter 331-compliant appointment letters, or the full workplace violence prevention program, which stands up the committee, facilitates and minutes the first meeting, and assembles the survey-readiness binder. To self-check first, the Chapter 331 compliance checklist includes the committee-composition line items.
The committee is small to assemble but easy to get wrong on the details. Anchor it on a genuine direct-care RN, resolve the conditional seats deliberately, and keep minutes — and the committee will hold up under any licensure survey.
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.