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 Chapter 331, the HHSC rule or provider letter for your license class, 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, so the target is ten of ten.
Written, facility-specific WVP plan
What a surveyor looks for: A written plan based on your practice setting, not a generic template: it names your units, patient population, and known risks, covers the eight items Section 331.004 lists, and is available to staff on request.
Source: HSC §331.004(a), (b), (e)
WVP committee with the required members
What a surveyor looks for: A committee that includes a registered nurse providing direct patient care; a physician providing direct care, whether employed, contracted, or independent (the only statutory exemption is an HCSSA with no such physician on staff); and a security-services employee, if any and if practicable.
Source: HSC §331.002
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. The statute does not require these by name; they are how you prove the committee exists and does its job.
Source: Evidence for HSC §331.002 and §331.004(d)
Annual training: delivered and documented
What a surveyor looks for: Evidence that health care providers and employees who provide direct patient care complete workplace violence prevention training at least annually, with rosters, dates, and content. Joint Commission-accredited hospitals also train at hire and when the program changes.
Source: HSC §331.004(b)(3); Joint Commission NPG.02.04.01 EP 2 (hospitals)
Written policy: confidential reporting and anti-retaliation protection
What a surveyor looks for: A written workplace violence prevention policy that encourages staff to provide confidential information to the committee, protects them from retaliation, and does not discourage anyone from contacting law enforcement.
Source: HSC §331.003; §331.005(b), (c)
Post-incident response procedures
What a surveyor looks for: Documented procedures for offering immediate post-incident services, including any necessary acute medical treatment, and for adjusting patient care assignments to the extent practicable, with records showing they were followed.
Source: HSC §331.005(a); §331.004(b)(8); Joint Commission NPG.02.04.01 EP 1 (hospitals)
Incident reporting, investigation, and trending
What a surveyor looks for: A system that captures incidents through your existing occurrence reporting, investigates them, and trends them over time, so the committee and leadership can see patterns and act on them.
Source: HSC §331.004(b)(4), (b)(7); Joint Commission NPG.02.04.01 EP 1 and NPG.11.01.01 EP 3 (hospitals); OSHA Pub. 3148
Annual worksite / environment-of-care analysis
What a surveyor looks for: A documented annual analysis of workplace violence risks across your environment of care, with identified hazards, owners, and follow-up actions tracked to closure.
Source: Joint Commission NPG.02.04.01 EP 3 (hospitals); OSHA Pub. 3148 (Component 2); supports HSC §331.004(b)(1), (b)(5)
Annual plan evaluation reported to the governing body
What a surveyor looks for: A documented annual review and evaluation of the plan by the committee, and proof the results were reported to your governing body: a recurring obligation under Chapter 331.
Source: HSC §331.004(d)
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 and not assembled under pressure.
Source: Good practice; organizes the evidence for HSC Ch. 331, the Joint Commission, and OSHA Pub. 3148
Take it with you
Get the fillable, print-ready PDF
The full checklist is already on this page. The download adds fillable In Place / Partial / Missing boxes, an evidence-location line for each item, and a binder-ready layout you can circulate.
What you get
- The full 10-point checklist as a fillable PDF: In Place, Partial, and Missing boxes and an evidence-location line 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: the target is ten of ten, and the statutory items come first.
- 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.
Download the checklist
Get the fillable, print-ready PDF 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; amended by SB 463, 2025); the HHSC rules by license class (26 TAC §505.55, §508.31, §509.70, §510.47, §511.79, §554.1920); HHSC PL 2024-10 and PL 2026-13; The Joint Commission Workplace Violence Prevention requirements (NPG.02.04.01 for hospitals; National Performance Goal #2a); 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 licensed in Texas who provides direct patient care (only an HCSSA with no such physician on staff is exempt from that seat); and a facility employee who provides security services, if any and if practicable. The plan is governed by HSC Chapter 331 and, for hospitals, 26 TAC §505.55.
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: a statutory step that is easy to overlook, 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?
Ten of ten In Place. Mark each of the 10 items In Place, Partial, or Missing: every Partial or Missing is a gap a surveyor can cite and a litigation-discovery exposure worth closing before a surveyor or a plaintiff’s attorney finds it. Items 1, 2, 4, 5, 6, 7, and 9 come straight from the statute, so close those first. If several items are Partial or Missing, a gap audit is the faster route.
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.