Texas HSC Chapter 331
Texas SB 240 Explained: HSC Chapter 331 Requirements
Texas SB 240 created Health & Safety Code Chapter 331, requiring covered healthcare facilities to adopt a workplace violence prevention plan. Here is what the statute requires.
Texas SB 240, enacted by the 88th Legislature in 2023, created Health & Safety Code Chapter 331 — Workplace Violence Prevention. It requires every covered healthcare facility to adopt a written, facility-specific WVP plan, convene a prevention committee, train staff at least annually, protect confidential reporting, respond to incidents, and evaluate the plan each year for the governing body.
This article is the operator-level explainer for the statute. It maps each requirement to the evidence a Texas HHSC licensing surveyor will open your binder to find. For the full cluster — coverage, committee composition, the annual evaluation, and the rules that implement the statute — see our pillar, Texas SB 240 & HSC Chapter 331 compliance.
#What SB 240 did
SB 240 added a new chapter to the Texas Health & Safety Code (Title 4, Subtitle H, Chapter 331). The bill became effective September 15, 2023, and gave covered facilities until September 1, 2024 to adopt and implement a workplace violence prevention policy and plan (Texas HSC Chapter 331; SB 240, 88th Leg., 2023).
The statute does not stop at "have a policy." It defines a recurring program — a committee that meets, training that refreshes annually, and an evaluation that returns to the board every year. That recurring structure is the reason Chapter 331 is best treated as a program of record rather than a one-time document drop.
#The six requirements, in order
Chapter 331 sets out six program elements. A surveyor checks each one against documentation, so it is useful to read them as a checklist.
| # | Requirement | What it means in practice |
|---|---|---|
| 1 | WVP committee | A standing committee that must include a registered nurse who provides direct patient care; a physician who provides direct care, if any are employed; and a security-services employee, if any are employed. |
| 2 | Written, facility-specific plan and policy | A plan that names your units, your risks, and your processes — not a purchased template. |
| 3 | Training at least annually | Education for applicable employees, refreshed at least once a year. |
| 4 | Confidential reporting + anti-retaliation | A policy that protects good-faith reporters and does not discourage contacting law enforcement. |
| 5 | Post-incident response | Acute treatment offered to staff directly involved, plus work-assignment adjustment as appropriate. |
| 6 | Annual plan evaluation to the governing body | The committee evaluates the plan at least annually and reports the results to the board. |
Each element is sourced directly from Chapter 331. The committee-composition rules (element 1) are the most frequently misread, and the annual evaluation (element 6) is the most frequently omitted — we cover both in depth in who must serve on a Chapter 331 committee and in our pillar's section on the annual review.
#1. The committee
The committee can be an existing committee that the facility re-authorizes for this purpose. What matters to a surveyor is the membership roster and appointment documentation showing the required categories are present. The RN-providing-direct-care seat is mandatory for every covered facility; the physician and security-services seats are required only if the facility employs people in those roles.
#2. The written, facility-specific plan
The single most common deficiency in this area is a generic template with another facility's name or boilerplate content. Chapter 331 requires a plan specific to your facility. In practice, facility-specificity is supported by a workplace violence risk assessment of your own environment of care — your ED, your high-risk units, your incident history.
#3. Training at least annually
The statutory cadence is "at least annually." Surveyors reconcile training rosters against the full employee census — including contracted and per-diem staff — so the most common training finding is a gap in the roster, not the absence of training entirely. Structured, documented delivery is what our healthcare staff training is built to produce.
#4. Confidential reporting and anti-retaliation
The reporting policy must protect anyone who reports an incident in good faith from discipline, discrimination, or retaliation — and it must not discourage employees from contacting law enforcement. A reporting policy that omits the law-enforcement language is a citable gap.
#5. Post-incident response
After an incident, the facility must offer immediate post-incident services, including any necessary acute medical treatment, to staff directly involved, and adjust their work assignment as appropriate. Surveyors look for evidence the process ran — not just policy language.
#6. The annual plan evaluation
This is the obligation that makes Chapter 331 a recurring duty. The committee must evaluate the plan at least annually and report the results to the governing body. The board-reporting step is distinct from the evaluation itself, and missing it is one of the most common findings. We walk through it in detail in the Chapter 331 annual plan evaluation.
#Where the rules live
Chapter 331 is the statute. Two HHSC instruments hard-wire it into the survey process:
- 26 TAC §133.55 — the HHSC rule for general and special hospitals, adopted in the Texas Register on October 11, 2024. It requires hospitals to establish or authorize a WVP committee and adopt, implement, and enforce a written plan.
- HCSSA Provider Letter PL 2024-10 (Revised) — applies Chapter 331 to home health and hospice agencies that employ two or more registered nurses.
Compliance is checked at licensure surveys. That is the mechanism that turns the statute into something a surveyor evaluates on-site.
#There is no fine schedule — and that matters
Chapter 331 carries no dedicated fine or penalty schedule. Enforcement surfaces two ways: as a licensure-survey deficiency requiring a plan of correction, and as exposure in post-incident litigation discovery, where counsel asks whether the facility had a plan, followed it, and acted on its data. The licensing agency may also take disciplinary action against the facility's license.
The absence of a fine does not lower the stakes — it raises the importance of survey-readiness and a defensible record. We unpack this in why Chapter 331 has no fines, and why that makes readiness more urgent.
#What to do next
- Confirm coverage. Determine whether your facility class — and, for nursing facilities and HCSSAs, your RN headcount — brings you under the statute. Start with is my facility covered by Chapter 331.
- Inventory your evidence. Map each of the six requirements to a document. The Chapter 331 compliance checklist gives you a line-by-line self-audit with a column for where the evidence lives.
- Score the gap. A focused survey-readiness audit tells you exactly where you stand against the Chapter 331 / 26 TAC §133.55 / PL 2024-10 checklist before a surveyor does.
Chapter 331 is not a heavy lift once it is structured correctly — but it is a recurring lift, by statute. Building it as a program of record, rather than a binder you assemble once, is what keeps a facility survey-ready year after year.
Sources: Texas Health & Safety Code Chapter 331 (SB 240, 88th Leg., 2023); 26 TAC §133.55 (adopted Oct. 11, 2024); HHSC Provider Letter PL 2024-10. This article is general compliance information, not legal advice.