Long-Term Care & Home Health
The Two-RN Coverage Test for Nursing Facilities & HCSSAs
How the two-RN threshold decides whether Texas Chapter 331 applies to your nursing facility or HCSSA: what the statute says, what it leaves open, and how to count defensibly.
For Texas nursing facilities and HCSSAs (since SB 463 took effect September 1, 2025, HCSSAs in every service category, not just home health), Health & Safety Code Chapter 331 applies only when the facility employs at least two registered nurses. That phrase is the whole test. The statute does not define "employs," and it does not limit the count to nurses who deliver hands-on care. At two or more, the full workplace violence prevention program is required.
This single threshold decides whether your facility carries the entire Chapter 331 obligation or none of it. Because long-term care and home health rely heavily on contracted and PRN clinicians, the counting is easy to get wrong, in both directions. This article works the test through, including the edge cases that trip up administrators and the one question the law leaves open.
#Why the threshold exists
Chapter 331, added by SB 240 in 2023 and expanded by SB 463 in 2025, covers six facility classes outright: general and special hospitals, mental hospitals, ambulatory surgical centers, freestanding emergency medical care facilities, intermediate care facilities (ICF/IID), and state supported living centers. For two classes, the legislature added a size proxy: nursing facilities (licensed under Ch. 242) and HCSSAs (licensed under Ch. 142, any service category since SB 463) are covered only if they employ at least two RNs. The RN count is a stand-in for organizational scale and clinical complexity. An agency covered only because SB 463 removed the home-health limitation had until September 1, 2026 to comply; everyone covered before keeps the September 1, 2024 obligation.
Primary source: Texas Health & Safety Code §331.001(3)(A) and (C) (SB 240, 88th Legislature, 2023, as amended by SB 463, 89th Legislature, 2025). HHSC Provider Letter PL 2024-10 (April 18, 2024) repeats the test for HCSSAs with a home health category of service that "employ two or more registered nurses (RN)."
#What the statute says, and what it leaves open
You will see it said that HHSC has defined an "employed RN" for this test, usually as a W-2 nurse with a current license regardless of job duties. PL 2024-10 contains no such definition, and neither does the statute. Here is what the primary sources actually give you.
What is settled:
- The test is the number of registered nurses the facility employs. Two is enough.
- The statute attaches no job-duty limit. It does not say "registered nurses who provide direct care." Compare the committee section, which does use that phrase for the RN seat: when the Legislature wanted a direct-care qualifier, it wrote one.
- The statute attaches no hours test. A part-time or PRN nurse who is your employee is still a nurse you employ.
So the conservative, defensible reading counts every registered nurse on your payroll, whatever the job title. A nurse working in administration, quality, intake, case management, or leadership counts. The Director of Nursing counts. A nurse who also serves as the administrator counts once. Many agencies that assume they are below the threshold are over it once non-bedside RNs are included.
What is open: neither Chapter 331 nor PL 2024-10 says how contracted or staffing-agency nurses are counted. There is no HHSC rule on the point yet. (HHSC proposed an HCSSA rule amendment, 26 TAC §558.243, on September 18, 2026; it is not adopted.) That gap is where the judgment call sits, and it is why the determination has to be written down.
#Worked examples
| Scenario | RNs on your payroll | Covered? |
|---|---|---|
| Agency with a Director of Nursing and 1 field RN, both employees | 2 | Covered |
| Agency with 1 RN who is both DON and administrator | 1 | Not triggered |
| Nursing facility with 4 RN employees (2 PRN, 2 full-time) | 4 | Covered |
| Agency with 1 full-time RN and 1 part-time RN, both employees | 2 | Covered |
| Agency with 1 RN employee and 3 contracted RNs | 1 | Open question: the statute does not address contracted nurses. Document the determination, and consider treating the agency as covered |
The pattern is clear: job title and hours do not take a nurse out of the count. The only genuinely uncertain row is the one that turns on contractors.
#The classification trap
The most consequential edge case is worker misclassification. Agencies sometimes treat nurses as "contractors" for payroll convenience when the actual working relationship looks like employment. If a nurse works a set schedule, under the agency's control over how the work is done, and is integrated into operations, calling them a "contractor" does not make the threshold disappear, and it creates separate employment-law exposure.
The safe course is to verify each nurse's actual working relationship, not the label on the paperwork, before concluding you are under the threshold, and to have counsel review a close call. An agency that wrongly assumes it is exempt because it miscounted can be cited at the licensure survey for having no program at all, a serious finding.
#Document the determination
Whatever the answer, put it in writing: the date, the names and roles counted, how contracted nurses were treated and why, and who made the call. A dated coverage determination is a defensible artifact at survey, and it is a document a surveyor or a plaintiff's attorney can be expected to ask for if the agency claims it was exempt. Recount whenever you hire.
#What happens at two
The moment a nursing facility or HCSSA reaches two employed RNs, the entire Chapter 331 program is required: a committee, a written policy, a written plan based on the practice setting, at-least-annual training, protection from retaliation for reporting, post-incident services, and an annual plan evaluation reported to the governing body. There is no phased or scaled-down version for a small agency; the obligation is binary.
For HCSSAs, the complete build is laid out in our PL 2024-10 program guide. For nursing facilities, see workplace violence prevention in nursing facilities. Both walk the program in the order a surveyor reviews it.
#Sitting just below the line
If you employ fewer than two RNs today, the program requirements are not triggered. But staffing in long-term care and home health changes fast, and a single hire flips coverage on immediately. Agencies near the line frequently build the program proactively, so that crossing the threshold does not leave them out of compliance at a survey window with no time to react. Building ahead is far cheaper than reconstructing a program under a plan-of-correction deadline.
#The honest stakes
Chapter 331 has no dedicated fine schedule. But miscounting the threshold and operating with no program is the worst posture to be in: it surfaces as a deficiency at the HHSC licensure survey requiring a plan of correction, and as stark exposure in post-incident litigation. Discovery will ask why a covered agency had no workplace violence program at all. The licensing agency may also take disciplinary action against the license.
The fastest way to settle coverage and posture in one step is a flat-fee survey-readiness audit, which confirms whether you are covered and scores your program against the full requirement set. You can also self-check against our Chapter 331 compliance checklist and read HHSC's guidance in our PL 2024-10 reference. VIGILO serves long-term care and home health and hospice agencies across Texas with flat-fee, subscription-based support.
VIGILO is a healthcare compliance, training, and consulting firm. It builds survey-defensible programs and documentation; it is not a security-guard, patrol, or investigations company, and it does not guarantee safety outcomes. This article is general compliance information, not legal advice; confirm your facility's coverage with qualified counsel. Every compliance claim traces to a named primary source.