Free self-check
The 10-Point Chapter 331 Survey-Readiness Checklist
This 10-point self-check shows how your facility’s workplace violence prevention program would hold up at a Texas HSC Chapter 331 licensure survey. Mark each item In Place, Partial, or Missing; any Partial or Missing is a potential survey deficiency and a litigation-discovery exposure. Aligned to Ch. 331, 26 TAC §133.55, PL 2024-10, the Joint Commission, and OSHA.
The self-check
The 10 points, in full
Mark each item In Place, Partial, or Missing. Any Partial or Missing is a potential survey deficiency and a litigation-discovery exposure.
Written, facility-specific WVP plan
What a surveyor looks for: A plan tailored to your facility — not a generic template — addressing your units, patient population, and known risks, as required under HSC Ch. 331.
Source: HSC Ch. 331; 26 TAC §133.55
WVP committee with the required members
What a surveyor looks for: A standing committee that includes a registered nurse providing direct patient care; a physician providing direct care if any are employed; and a security-services employee if any are employed.
Source: HSC Ch. 331
Committee charter, appointments, and meeting minutes
What a surveyor looks for: A charter, dated appointment letters, a current roster, and minutes showing the committee actually meets and acts.
Source: HSC Ch. 331
Annual employee training — delivered and documented
What a surveyor looks for: Evidence that all staff complete WVP training at least annually, with rosters, dates, content, and (for new hires) orientation training.
Source: HSC Ch. 331; Joint Commission (HR, eff. Jan. 1, 2022)
Confidential reporting policy with anti-retaliation protection
What a surveyor looks for: A written policy that lets staff report incidents confidentially, prohibits retaliation, and does not discourage employees from contacting law enforcement.
Source: HSC Ch. 331
Post-incident response procedures
What a surveyor looks for: Documented procedures for acute treatment of assaulted staff and adjustment of work assignments after an incident, with records that they were followed.
Source: HSC Ch. 331; Joint Commission (EC)
Incident reporting, tracking, and trending
What a surveyor looks for: A system that captures incidents and trends them over time — the basis for the worksite analysis the Joint Commission expects.
Source: Joint Commission (EC, eff. Jan. 1, 2022); OSHA Pub. 3148
Annual worksite / environment-of-care analysis
What a surveyor looks for: A documented annual analysis of WVP risks across your environment of care, with identified hazards and follow-up actions.
Source: Joint Commission (EC); OSHA Pub. 3148 (Component 2)
Annual plan evaluation reported to the governing body
What a surveyor looks for: A documented annual evaluation of the WVP plan presented to your governing body — the statutory recurring obligation under Ch. 331.
Source: HSC Ch. 331
A maintained, indexed survey-readiness binder
What a surveyor looks for: One current, organized file containing all of the above — the program of record — so evidence is produced in minutes, not reconstructed under pressure.
Source: HSC Ch. 331; Joint Commission; OSHA Pub. 3148
Take it with you
Get the fillable, print-ready PDF
The full checklist is already on this page. The download adds In Place / Partial / Missing boxes and a binder-ready layout you can circulate.
What you get
- The full 10-point checklist as a fillable PDF with In Place / Partial / Missing boxes for each item.
- A plain-English “what a surveyor looks for” note on every point, written from the surveyor’s perspective.
- A simple scoring guide — six or more In Place is a reasonable program; fewer signals it’s time for a gap audit.
- The primary source behind each requirement, so every item is defensible and nothing is fabricated.
- A clear next step: where a Survey-Readiness Audit (from $500) turns the self-check into a scored, prioritized gap report.
Email me the checklist
Get the fillable, print-ready PDF emailed to you for your survey-readiness binder. The full checklist is already on this page — the download is yours to keep and circulate.
Primary sources
TX HSC Chapter 331 (SB 240, 2023); 26 TAC §133.55; HHSC PL 2024-10; The Joint Commission Workplace Violence Prevention requirements (R3 Report 45, effective Jan. 1, 2022 for hospitals); OSHA General Duty Clause §5(a)(1) and Publication 3148.
Checklist FAQ
Common questions
Does Texas HSC Chapter 331 carry a fine for non-compliance?
No. Chapter 331 has no dedicated fine schedule. The exposure is practical, not a fixed penalty: a gap surfaces as a deficiency at your licensure survey and, after a serious incident, as a discovery item in litigation. That is why the urgency is survey-readiness and a defensible record, not a fictional fine.
Who must sit on the Chapter 331 workplace violence prevention committee?
The committee must include a registered nurse who provides direct patient care; a physician who provides direct patient care, if any physician is employed; and a security-services employee, if any are employed. The plan is governed by HSC Chapter 331 and, for hospitals, 26 TAC §133.55.
How often must the workplace violence prevention plan be evaluated?
At least annually. Chapter 331 requires the committee to evaluate the written plan each year and report that evaluation to the facility’s governing body — the single most overlooked statutory step, and the recurring obligation that makes compliance an ongoing program rather than a one-time project.
What score on this checklist means my program is survey-ready?
Mark each of the 10 items In Place, Partial, or Missing. Six or more In Place is a reasonable program; fewer signals it is time for a gap audit. Any Partial or Missing is a potential survey deficiency and a litigation-discovery exposure worth closing before a surveyor or a plaintiff’s attorney finds it.
Turn the self-check into a scored gap report
A flat-fee Survey-Readiness Audit scores all 10 points against Chapter 331, the Joint Commission, and OSHA, with prioritized findings and a defined path to compliance.